COLLEGE   OF  OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


^^ 


A    MANUAL    OF     SURGICAL    TREATMENT 


CHEYNE   AND  BURGHARD'S 
MANUAL    OF   SURGICAL   TREATMENT. 

CONTENTS    OF   THE   VOLUMES. 

VOLUME  I.. 
Price  2is.  net. 

The  Treatment  of  General  Surgical  Diseases,  including  Inflammation, 
Suppuration,  Ulceration,  Gangrene,  Wounds  and  their  Complications, 
Infective  Diseases  and  Tumours,  Deformities. 

With  an  Appendix  upon  the  Administration  of  Anaesthetics  by  DR.  SILK,  and  the 
Examination  of  the  Blood  by  DR.  W.  D'EsTE  EMERY. 

VOLUME   II. 

The  Treatment  of  the  Surgical  Affections  of  the  Skin  and  Subcutaneous 
Tissues,  the  Nails,  the  Lymphatic  Vessels  and  Glands,  the  Bursse,  the 
Muscles,  the  Tendons  and  Tendon  Sheaths,  the  Nerves,  the  Blood  Vessels 
and  the  Bones :  Amputations. 

VOLUME  III. 

The  Treatment  of  the  Surgical  Affections  of  the  Joints,  the  Head  and 
Face,  and  the  Spine. 

VOLUME  IV. 

The  Treatment  of  the  Surgical  Affections  of  the  Tongue,  the  Mouth, 
the  Pharynx  and  Oesophagus,  the  Stomach,  the  Intestines,  the  Rectum  and 
Anus. 

VOLUME  V. 

The  Treatment  of  the  Surgical  Affections  of  the  Pancreas,  Liver  and 
Spleen,  the  Genito-Urinary  Organs,  the  Larynx  and  Neck,  the  Thorax  and 
the  Breast. 


A  i  Manual    of 

L 

Surgical    Treatment7 

\BY 

SIR  W.  WATSON  CHEYNE,  BART.,  C.B. 

D.Sc.,  LL.D.,  F.R.C.S.,  F.R.S. 

Hon.  Surgeon  in  Ordinary  to  H.  M.  the  King ;    Senior  Surgeon  to  King's  College  Hospital 

AND 

F.  F.  BURGHARD 

M.S.  (Lond.),  F.R.C.S. 

Surgeon  to  King's  College  Hospital,  and  Senior  Surgeon  to  The  Children's  Hospital, 
Paddington  Green 

NEW     EDITION 

ENTIRELY   REVISED   AND    LARGELY    REWRITTEN    WITH    THE    ASSISTANCE    OF 

T.  P.  LEGG 

M.S.  (Lond.),  F.R.C.S. 

Surgeon  to  the  Royal  Free  Hospital  ;  Assistant  Surgeon  to  King's  College  Hospital 

AND 

ARTHUR    EDMUNDS 

M.S.  (Lond.),  F.R.C.S. 

Surgeon  to  the  Great  Northern  Central  Hospital  ;    Surgeon  to  Out-patients, 
The  Children's  Hospital,  Paddington  Green 

In    Five    Volumes 
VOL.   I. 

The    Treatment  of  General  Surgical  Diseases,    including  Inflammation,  Suppuration, 

Ulceration,  Gangrene,  ]Vounds  and  their  Complications,  Infective  Diseases 

and  Tumours,   Deformiti-   . 

With  an  APPENDIX  upon  the  Administration  of  Anastlietics  b\>  DR.   SILK, 
and  the  Examination  of  the  Blood,  by  Dr.    W.  D'ESTE  EMERY 


LEA   &    FEBIGER 

PHILADELPHIA   AND   NEW   YORK 

1912 


I  <\  15- 
V.\ 


TO 
THE   RIGHT  HON. 

LORD  LISTER,  O.M.,  LL.D.,  F.R.S. 

THE   FOUNDER   OF   MODERN  SURGERY 

WITHOUT  WHOSE  WORK   MUCH   OF  THIS   BOOK 

COULD    NOT   HAVE   BEEN   WRITTEN. 


A 

•" 
v, 


PREFACE 

TO 

REVISED    EDITION. 


SINCE  the  first  edition  of  this  work  was  published  many  changes  have 
naturally  occurred  in  the  field  of  Surgical  Treatment.  Attempts  have 
been  made  from  time  to  time  to  incorporate  the  most  essential  of 
these  in  successive  impressions,  but  it  is  always  difficult  to  interpolate 
new  matter  of  this  kind  satisfactorily  without  extensive  revision  of 
the  entire  work.  It  has  therefore  seemed  best  to  revise  the  matter 
throughout  and  to  alter  in  it  whatsoever  was  necessary  to  bring  it 
up  to  date.  The  original  scheme  of  the  work  has  been  adhered  to ; 
to  depart  from  it  would  have  been  to  abandon  the  fundamental  idea 
upon  which  it  was  based.  Every  part  of  the  book,  however,  has  been 
thoroughly  revised,  and  a  considerable  part  has  been  re-written. 

The  pressure  of  other  work  rendered  it  impossible  for  the  original 
authors  to  undertake  a  task  of  such  magnitude  with  any  hope  of  being 
able  to  complete  it  within  a  reasonable  time.  In  Messrs.  T.  P.  Legg 
and  Arthur  Edmunds  they  have  been  fortunate  in  securing  collaborators 
who  have  rendered  their  task  possible,  and  to  them  they  are  under  a 
great  obligation.  To  their  colleagues  Dr.  Silk,  Dr.  D'Este  Emery,  Dr. 
Arthur  Whitfield  and  Mr.  A.  D.  Reid,  they  are  also  much  indebted  for 
help  in  the  several  departments  of  treatment  with  which  these  gentlemen 
are  specially  concerned.  Mr.  Arthur  Edmunds,  in  addition  to  his  share 
in  the  revision,  has  provided  a  number  of  the  new  illustrations ;  Messrs. 
F.  Butterworth  and  S.  A.  Sewell  have  drawn  the  remainder. 

Messrs  Down  Bros. ,  Allen  &  Hanburys,  Barth,  and  others  have  kindly 
allowed  the  reproduction  of  many  instrument  blocks  from  their  cata- 
logues. Other  figures  have  been  reproduced  by  permission  of  their 
authors  or  publishers,  and  the  source  from  which  they  are  derived  will 
be  found  duly  acknowledged  in  the  text. 

LONDON,  1911. 
i.  vii  b 


AUTHORS'   PREFACE 

TO 

THE    FIRST    EDITION. 


THE  subject  of  Surgery  has  now  become  so  extensive  that  any  work 
attempting  to  deal  with  it  in  an  exhaustive  manner  must  necessarily  be 
so  large  and  unwieldy  as  to  be  suitable  only  for  purposes  of  reference, 
or  for  the.  use  of  those  who  devote  themselves  exclusively  to  its  practice. 
In  any  text-book  of  convenient  size  the  information  given  in  certain 
branches  of  the  subject  must  therefore  be  considerably  condensed,  and, 
as  the  first  essential  for  the  beginner  is  to  have  the  fullest  knowledge  of 
the  nature  and  characters  of  the  diseases  that  he  has  to  study,  special 
stress  is  usually  laid  upon  pathology,  symptomatology,  and  diagnosis.  For 
the  practitioner,  on  the  other  hand,  who  is  already  acquainted  with  these 
points,  the  great  essential  is  full  and  detailed  information  as  to  the  best 
methods  of  treatment. 

We  have  ourselves  frequently  experienced  the  want  of  detailed  infor- 
mation, especially  as  regards  the  after-treatment  of  our  cases,  and  have 
had  to  learn  the  best  methods  of  procedure  from  experience.  Nothing 
can  of  course  replace  experience,  but  it  is  often  of  the  greatest  advantage 
to  have  a  detailed  record  of  that  of  others  upon  which  to  base  one's  work. 
It  is  this  want  that  the  present  work  is  intended  to  supply.  We  have 
tried  to  put  ourselves  in  the  place  of  those  who  have  to  treat  a  given 
case  for  the  first  time,  and  we  have  endeavoured  to  supply  them  with 
details  as  to  treatment  from  the  commencement  to  the  termination  of  the 
illness.  We  have  assumed  that  the  reader  is  familiar  with  the  nature  and 
diagnosis  of  the  disease,  and  we  only  refer  to  the  pathology  and  symptoms 
in  so  far  as  it  is  necessary  to  render  intelligible  the  principles  on  which 
the  treatment  is  based,  and  the  various  stages  of  the  disease  to  which 
each  particular  method  is  applicable. 

We  have  purposely  avoided  attempting  to  give  anything  like  a  com- 
plete summary  of  the  various  methods  of  treatment  that  have  from  time 


x  PREFACE  TO  THE  FIRST  EDITION 

to  time  been  proposed :  to  do  so  would  merely  confuse  the  reader. 
Only  those  plans  are  described  which  our  experience  has  led  us  to  believe 
are  the  best,  but  with  regard  to  these  we  have  endeavoured  to  state 
exactly  and  in  detail  what  we  ourselves  should  do  under  given  circum- 
stances. In  some  cases  no  doubt  several  methods  of  treatment  are  of 
equal  value,  and  while  we  have  discussed  at  length  that  which  we  have 
ourselves  been  led  to  adopt,  we  have  referred  shortly  to  the  others. 

We  have  not  mentioned  all  the  exceptional  conditions  that  may  be 
met  with,  but  we  have  endeavoured  to  include  all  the  circumstances  with 
which  the  surgeon  is  most  commonly  called  upon  to  deal.  The  task  has 
been  one  of  some  difficulty,  the  more  so  as  we  have  had,  to  a  certain 
extent,  to  break  new  ground.  This  must  serve  as  our  excuse  for  the  many 
shortcomings  in  the  work. 

LONDON,  April,  1899. 


CONTENTS 

OF 

THE    FIRST    VOLUME. 
DIVISION  I. 

INFLAMMATION   AND   ITS   SEQUELAE. 

CHAPTER  I. 
INFLAMMATION. 

PAGES 

ACUTE  INFLAMMATION — Definition. — Pathology  :  Changes  in  the  early 
stages — Changes  in  the  later  stages. — Symptoms. — Treatment :  Re- 
moval of  Cause — Local  Treatment :  Position — Blood-letting — -Cupping 
— Scarifications — Free  Incisions. — Cold — Heat. — Bier's  Treatment. — 
General  Treatment :  Purgatives — Drinks — Drugs — Food. — Prognosis  1-15 

CHRONIC  INFLAMMATION — Pathology — Causes — Symptoms. — Treatment : 
Local  Treatment,  Rest — Counter-irritation — Free  Incision — Pres- 
sure— Massage — General  Treatment  ......  16-24 

CHAPTER  II. 

ACUTE  SUPPURATION. 

ACUTE  SUPPURATION — Definition — Causes — Mode  of  Extension. — Circum- 
scribed Acute  Abscess:  Symptoms — Local  Treatment:  Opening — 
Drainage — After-treatment — General  Treatment. — Diffuse  Cellulitis : 
Symptoms — Local  Treatment — After-treatment — General  Treatment  25-38 

CHAPTER  III. 
ULCERATION. 

ULCER  ATION — Definition — Classification — Causes     ....  39~43 

VARIETIES  OF  ULCER — Simple — Inflamed — Irritable — Weak — Diphtheritic 
and  Phagedenic  —  Varicose  —  Callous  —  Haemorrhagic  —  Pressure — 
Paralytic — Diabetic       ........  43~45 

xi 


xii  CONTENTS  OF 

PAGES 

DANGERS  OF  ULCERS  ..........  46 

TREATMENT   OF   ULCERS   IN    GENERAL— Removal   of   Cause — Rest — Pro- 
motion of  Venous  Return— Absorption  of  Exudation — Avoidance  of 
Irritation — Disinfection. — Skin  Grafting — Treatment  when  a  Patient 
cannot  lie  up         .          .          .          .          .          .          .          .          .          .       46-60 

TREATMENT  OF  SPECIAL  FORMS  OF  ULCER — Simple — Inflamed — Weak — 
Irritable — Phagedenic — Varicose — Callous — Pressure — Paralytic — Per- 
forating Ulcer  of  Foot — Diabetic  .......  60-66 

CHAPTER  IV. 
GANGRENE. 

DEFINITION — Classification — Symptoms — Treatment,  Local  and  General 

— Etiological  Classification  ........  67-69 

DIRECT  GANGRENE  :  Gangrene  due  to  Crushing — Pressure  Gangrene — 

Gangrene  from  Acute  Inflammation  ......  69-72 

INDIRECT  GANGRENE  :  Senile  Gangrene — Obstructive  Gangrene — Gangrene 
from  Imperfect  Innervation — Diabetic  Gangrene — Gangrene  after 
Acute  Fevers — Gangrene  from  Ergot  ......  72-82 

INFECTIVE  GANGRENE — Acute  Traumatic  Gangrene — Phagedena — Can- 

crum  Oris  ,  82-86 


DIVISION  II. 

WOUNDS  AND  THEIR  COMPLICATIONS. 

CHAPTER  V. 

WOUNDS. 

OPERATIONS  AND  THEIR  MANAGEMENT — Preparation  of  the  Patient :  Mental 

Attitude — Food — Time  of  Operation         ......        87-89 

THE  OPERATING  ROOM  and  its  Accessories       ......        89-91 

INSTRUMENTS,  Ligature  Materials  and  Dressings,  and  their  Sterilisation     .        92-95 
PREPARATION  of  Sponges,  Swabs  and  Dressings      .....       95-99 

DANGERS  OF  OPERATIONS— £;TC/MS«W  of  Micro-organisms  :  Disinfection  of 
the  Skin — Disinfection  of  the  Hands.  Hemorrhage  :  Spontaneous 
Arrest  of — Means  of  Controlling — Tourniquet — Esmarch's  Bandage — 
Lister's  Method  —  Ligature  —  Cautery  —  Torsion  —  Pressure  —  Cold — 
Heat — Styptics — Symptoms  of  Serious  Loss  of  Blood — Transfusion 
and  Infusion.— Shock  :.  Symptoms — Treatment,  prophylactic  and 
when  established. — Entry  of  Air  into  Veins — Syncope  .  .  .  99-124 
AFTER-TREATMENT  OF  OPERATIONS — Feeding — Pain — Aperients  .  .  124-126 

CHAPTER  VI. 

MODES  OF  HEALING  OF  WOUNDS. 

HEALING   by   '  First  Intention  ' — Healing  by  Blood  Clot — Healing   under 

a  Scab — Healing  by  Granulation — Healing  by  Union  of  Granulations  127-131 


THE  FIRST  VOLUME  xiii 

CHAPTER  VII. 

THE  TREATMENT  OF  INCISED  WOUNDS. 

PAGES 

INCISED  WOUNDS — Classification  .......  132 

TREATMENT  OF  WOUNDS  MADE  BY  THE  SURGEON  THROUGH   UNBROKEN 
SKIN — Apposition   of  Edges — Approximation   of  Deeper   Structures — 
Sutures  :    When  there  is  no  tension — When  there  is  great  tension — 
When   there   is   moderate   tension. — Avoidance  of  Movement — Avoid- 
ance of  Irritation — Drainage — Dressings — After-progress    of    Wound — 
Treatment  without  A  ntiseptics — Causes  of  failure  to  secure  healing  by 
First  Intention — Treatment  when  Sepsis  occurs — Treatment   when    the 
Edges   are  not   brought  together :     Thiersch's   Skin    Grafting— Plastic 
Operations — Granulating  Flaps — Occurrence  of  Sepsis  in  Open  Wounds   132-161 
TREATMENT  OF  WOUNDS  THAT  CANNOT  BE  KEPT  ASEPTIC — Wounds  of 

Mucous  Membranes        .........    161-163 

TREATMENT  OF  INCISED  WOUNDS  INFLICTED  ACCIDENTALLY     .          .          .   163-165 
TREATMENT  OF  WOUNDS  ALREADY  SEPTIC — Treatment  of  Open  Granulating 

Wounds — Treatment  when  Septic  Sinuses  are  present        .          .          .    165-167 


CHAPTER  VIII. 

PUNCTURED,    CONTUSED,    LACERATED,    AND    POISONED 
WOUNDS;    BURNS,   SCALDS,   AND    FROST-BITES. 

PUNCTURED  WOUNDS — Characters — Results — Treatment          .          .          .  168-169 

CONTUSIONS  AND  CONTUSED  WOUNDS — Characters — Causes — Treatment    .  169-170 

LACERATED  WOUNDS— Treatment          .......  170-172 

POISONED  WOUNDS — Lupus  Anatomicus — Local  Septic  Infection — General 

Septic  Infection  .........  172-173 

BURNS  AND  SCALDS — Causes — Symptoms — Causes  of  Death. — Treatment, 

General  and  Local  .........  174-180 

EFFECTS  OF  INTENSE  COLD — Chilblains — Ulcers— Frostbite — Treatment, 

Prophylactic  and  Curative      ........  180-184 


CHAPTER  IX. 

INFECTIVE  DISEASES  OF  WOUNDS. 

SEPTIC  INTOXICATION — Symptoms — -Treatment,  Local  and  General  .          .  185-188 

TRAUMATIC  FEVER — Treatment     .          .          .          .          .          .    •     .          .  188-189 

ACUTE  SCEPTIC.^MIA — Symptoms — Treatment         .....  189-190 

CHRONIC  SCEPTIC^MIA  OR  HECTIC  FEVER — Treatment,  Local  and  General  190-192 

ACUTE  PYAEMIA — Pathology — Treatment,  Local  and  General  .  .  .  192-195 

CHRONIC  PY^MIA — Treatment •  i95~I96 

ERYSIPELAS — Symptoms — Varieties — Pathology — Treatment,  General  and 

Local 196-199 

TETANUS — Symptoms — Varieties- — Causes — Treatment,  Prophylactic  and 

Curative                                                                                      .          •          •  199-203 


xiv  CONTENTS  OF 

CHAPTER  X. 

AFFECTIONS  OF  CICATRICES. 

PAGES 

CHELOID — Causes — Treatment       ........  204-206 

CONTRACTING  CICATRIX — Treatment      .......  206 

PAINFUL  CICATRIX — Treatment     ........  206-207 

ADHERENT  CICATRIX — Treatment.          .......  207 

EPITHELIOMA — Treatment    .........  207-208 

DIVISION  III. 

SYPHILIS  AND  TUBERCULOSIS. 

CHAPTER  XI. 

SYPHILIS. 

ACQUIRED  SYPHILIS — Primary  Stage — Secondary  Stage — Tertiary  Stage — 
Treatment — Prophylaxis — Treatment  by  '  Salvarsan' — by  Mercury  and 
the  Iodides. — Primary  Syphilis  :  Treatment,  General  and  Local. — 
Secondary  Syphilis :  Treatment,  General  and  Local.  —  Tertiary 
Syphilis  :  Treatment,  General  and  Local  .....  209-226 

HEREDITARY  SYPHILIS — Treatment        .......   226-227 

CHAPTER  XII. 

TUBERCULOSIS. 

TUBERCULOSIS  —  Seats  —  Accessory  Factors  —  Pathology  —  General  Treat- 
ment    228-233 

CHRONIC  ABSCESS — Treatment      ........   233-236 

DIVISION  IV. 
TUMOURS. 

CHAPTER  XIII. 
TUMOURS. 

TUMOURS — Definition — Clinical  Classification — Histological  Classification  .   237-238 
TUMOURS  OF  THE  CELLULAR  TYPE — 

EPITHELIAL  TUMOURS — Benign  Varieties  :  Papillomata — Warts — Horns 
— Corns — Adenomata. — Malignant  Varieties  :  Carcinomata — Mode  of 
Spread — Treatment  of  Various  Forms. — Endotheliomata  .  .  .  238-243 

TUMOURS  OF  THE  CONNECTIVE  TISSUE  TYPE — Malignant  Forms  :  Sar- 
comata :  Round-Celled,  Spindle-Celled,  Myeloid,  Melanotic,  Alveolar, 
Osteo-Sarcoma,  Chondro-Sarcoma — Treatment — Prognosis — Explora- 
tory Incision— Operations  J  Radical,  Partial  and  Palliative — Treat- 
ment of  Inoperable  Cases. — Benign  Varieties  :  Myxoma — Fibromata, 
Hard  and  Soft — Moles — Lipomata,  Diffuse  and  Circumscribed — 
Chondromata — Osteomata,  Ivory  and  Spongy  ....  243-254 


THE  FIRST  VOLUME  xv 

PAGES 

TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES — Myomata — Neuro- 
mata and  Gliomata — Angiomata,  Capillary  and  Cavernous  :  Treat- 
ment— Excision — Electrolysis — Caustics — Freezing — Radium  —  Lym- 
phangiomata,  Simple,  Cavernous,  and  Cystic — Lymphadenoma — 
Lympho-sarcomata — Cysts — Complex  Tumours  :  Treatment  .  .  254-265 


DIVISION  V. 

DEFORMITIES. 

CHAPTER  XIV. 
DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES. 

SUPERFLUOUS  DIGITS — Treatment :  When  the  Digit  is  separate — When 
there  is  an  actual  Articulation  between  the  Digit  and  Metacarpal  Bone 
— -When  there  is  a  Supernumerary  Metacarpal  Bone  articulating  with 
the  Carpus — In  the  case  of  a  Bifid  Finger  .....  267-270 

WEBBED  DIGITS — Treatment :  When  the  Web  is  broad — When  the  Web 

is  narrow — When  the  Bones  are  united  ......  270-275 

HAMMER  TOE — Pathological  Changes — Treatment :  Appliances — Excision 

of  the  Head  of  the  first  Phalanx — After-treatment  ....  275-279 

HALLUX  VALGUS  AND  BUNION — Treatment :  In  the  early  Stages  :  Boots 
— Toe-post — Splints — Spring  Apparatus — When  the  Deformity  is 
more  severe — When  Suppuration  has  occurred  ....  279-286 

HALLUX  FLEXUS — HALLUX  RIGIDUS — Treatment   .....   286-287 

ANTERIOR  METATARSALGIA  OR  MORTON'S  NEURALGIA — Treatment :  Pallia- 
tive and  Operative  .........  287-289 

CONTRACTIONS  OF  THE  FINGERS — Treatment  .....  289 

DUPUYTREN'S  CONTRACTION  —  Pathology  —  Treatment :  Subcutaneous 
Division  of  Palmar  Fascia — Open  Operations  :  Excision  of  Con- 
tracted Fascia — V-shaped  Incision  ......  289-296 

CONTRACTIONS  AFTER  BURNS— Treatment       ......   296-297 

CONGENITAL  ELEVATION  OF  THE  SCAPULA — Treatment  ....   297-298 

CHAPTER  XV. 
FLAT  FOOT. 

FLAT  FOOT  —  Causes  —  Pathological   Changes  —  Symptoms  —  Treatment : 
Acute  Flat  Foot :  Fixation — Exercises — Whitman's  Spring — Boots. — 
When  the  Condition  is  Chronic. — A  dvanced  and  Extreme  Cases :  Excision 
of  the  Head  of  the  Astragalus — Ogston's  Operation — Removal  of  a 
wedge-shaped  portion  of  the  Tarsus        ......   299-310 

WEAK  ANKLES — Treatment  ........   310-311 

INTOEING — Treatment 311 

CHAPTER  XVI. 
CLUB  FOOT. 

CAUSES  AND  PATHOLOGICAL  CHANGES — Treatment :   General  Indications  .   312-315 
CONGENITAL   CLUB-FOOT — General  points  in   Treatment  of  the   various 

groups  of  cases     ..........   315-319 

ACQUIRED  CLUB-FOOT — General  points  in  Treatment  of  the  various  forms    319-321 


xvi  CONTENTS  OF 

PAGfeS 

THE  INDIVIDUAL  FORMS  OF  CLUB-FOOT  : 

TALIPES  EQUINUS — Treatment  of  First  Group  :   Division  of  Tendo  Achillis 
— Accidents — After-Treatment. — Treatment  of  Second  Group  :  Division 
of    Plantar    Fascia — After-Treatment. — Treatment    of    Third    Group  : 
Excision  of  the  Astragalus — Partial   Resection  of   the  Astragalus — 
Amputation  ..........    321-334 

TALIPES  CAVUS — Treatment  ........   334-335 

TALIPES     CALCANEUS — Treatment :      By    Massage    and    Apparatus — By 
Shortening  the  Tendo  Achillis — By  Muscle  and  Tendon  Transplanta- 
tion .....  .   335-342 

TALIPES  VALGUS — Pathological  Changes — Treatment       ....   342-344 

TALIPES  EQUINO- VALGUS — TALIPES  VARUS     ......  344 

TALIPES   EQUINO- VARUS — Pathological   Changes — Treatment  :     When  the 
Deformity  can  be  reduced  by  Manipulation  alone  :    Manipulations — 
Apparatus. — When  there  are  tight  Structures  :    Tenotomy — Division  of 
the   Plantar   Fascia — Syndesmotomy — Wrenching — Scarpa's   Shoe. — 
The  most  severe   Cases  :    Forcible  Restoration— Phelps'   Operation — 
Amputation — Osteoplastic  Operations      ......   344-361 

CLUB-HAND — Treatment       .........   361-362 

CHAPTER  XVII. 
CURVED  TIBIA  AND  FIBULA. 

CURVED  TIBIA  AND  FIBULA — Treatment,  General :  Food — Clothing — 
Hygiene — Drugs. — Local : '  In  the  early  stages — In  the  more  advanced 
cases — When  solidification  has  occurred — After-treatment  .  .  363-370 

CHAPTER  XVIII. 
GENU  VALGUM  :    GENU  VARUM  :    GENU  RECURVATUM. 

GENU  VALGUM — Causes — Treatment :  General  and  Local  in  the  various 
stages —  Manipulations —  Massage  —  Splints.  - —  Osteotomy  —  After- 
treatment 37J-383 

GENU  VARUM — Treatment 383-384 

GENU  RECURVATUM — Treatment  .......   384-385 


CHAPTER  XIX. 
CURVATURES  OF  THE  NECK  OF  THE  FEMUR. 

COXA     VARA — Causes — Pathological    Changes — Treatment :      In     Young 

Children — Mechanical — Operative.— In  Young  Adults         .          .          .   386-391 
COXA  VALGA 392 

CHAPTER  XX. 

CONGENITAL  DISLOCATION  OF  THE  HIP. 

CONGENITAL  DISLOCATION  OF  THE  HIP — Pathology — Treatment :  In 
Infancy — Lorenz's  Non-Operative  Method — Operative  Methods — 
Summary  of  Treatment  .  ....  393-402 


THE  FIRST  VOLUME  xvii 

CHAPTER  XXI. 
KYPHOSIS:  SCOLIOSIS. 

PAGES 

KYPHOSIS — In  Infancy — In  Adult  Life — Treatment          ....   403-404 

SCOLIOSIS  : 

Causes — Pathological  Changes— Symptoms — Examination — Prognosis — 
Treatment  :  Prophylaxis — When  there  is  obliquity  of  the  pelvis — 
When  heavy  weights  are  carried  upon  one  side — When  there  is  weak- 
ness of  the  spinal  muscles — When  there  has  been  disease  within  the 
thorax — When  Scoliosis  has  developed — The  Scoliosis  of  Infancy — The 
Scoliosis  of  Childhood— The  Curvatures  of  Adolescence — -The  Scoliosis 
of  Adult  Life  ..........  405-423 

MUSCULAR  GYMNASTIC  EXERCISES  FOR  SCOLIOSIS    .....   423-439 


APPENDIX. 

ANESTHETICS. 
By  DR.  J.  F.  W.  SILK. 

PART  I. — GENERAL  ANAESTHESIA  : 

PREPARATION  OF  THE  PATIENT — Purge — Diet — Nutrient  Enema — 

Alcohol — Hypodermic  Medication — Auscultation — Position  .  .  443-446 

CHOICE  OF  THE  ANAESTHETIC — Factors  determining       ....   446-448 

NITROUS  OXIDE — Properties— Cases  Suitable — Apparatus  and  Adminis- 
tration —  Phenomena  —  Complications  —  Af  ter-Effects  —  Prolonged 
Method  ...........  448-452 

ETHER — Properties — Cases  Suitable — Apparatus  and  Administration — 
Stages  in  Administration — Special  Points — Dangers — After-Effects 
— Nitrous  Oxide  and  Ether  combined.  .....  452-458 

CHLOROFORM  —  Properties  —  Cases  Suitable  —  Preparation — Apparatus 
and  Administration  —  Phenomena  —  After-Effects  —  Dosimetric 
Methods  ...........  458-463 

MIXTURES — A  .C.E.  Mixture  :  Properties — Apparatus  and  Adminis- 
tration— Objections  .........  463-466 

ETHYL  CHLORIDE     ..........  466-467 

ADMINISTRATION  IN  SPECIAL  CASES — Intra-cranial  Operations — Opera- 
tions about  Nose  and  Mouth  —  Enlarged  Thyroids  —  Severe 
Operations— Alcoholics — Status  lymphaticus  ....  467-471 

DIFFICULTIES  AND  DANGERS — Syncope — Respiratory  Paralysis — Signs 

of  Danger — Treatment,  Prophylactic  and  Active  ....  471-477 

AFTER-TREATMENT— Sickness — '  Surgical  Shock  ' — Diet        .          .          .   477-480 

PART  II. — LOCAL  ANAESTHESIA  : 

Advantages — Objections — Cases  Suitable. — Freezing  :    Ether  Spray — 
Ethyl  Chloride — Anasstile. — Drugs  :    Cocaine  :    Instillation — Spray — 
Painted. — Hypodermically — Infiltration — Conduction  Anaesthesia — 
Spinal    Anaesthesia :      Apparatus    and    Procedure — Difficulties    and 
After-Effects 480-489 


xviii  CONTENTS  OF  THE   FIRST  VOLUME 

THE  EXAMINATION  OF  THE  BLOOD   IN   SURGICAL 
CONDITIONS. 

BY  DR.  W.  D'ESTE  EMERY. 

PAGES 

THE    ENUMERATION    of    the    Leucocytes — Thoma's    Hsemocytometer — 

Practical  Application     .........   490-496 

THE  DIFFERENTIAL  LEUCOCYTE  COUNT  ......   496-499 

THE  IODINE  REACTION         .........  499 

THE  EXAMINATION  OF  THE  RED  CORPUSCLES  AND  HAEMOGLOBIN — Haldane's 

Haemoglobinometer        .........   499-502 

THE  BACTERIOLOGICAL  EXAMINATION  OF  THE  BLOOD       ....   502-503 

THE  OPSONIC  INDEX   ..........   503-504 

THE  FREEZING  POINT  OF  THE  BLOOD  OR  SERUM   .....   504-506 

SUMMARY  ...........   506-508 

THE  WASSERMANN  REACTION       ........   508-513 

PREPARATION  OF  VACCINES — Preparation  of  the  Culture— Preparation  of 
the  Emulsion — Sterilisation  of  the  Vaccine — Counting  the  Emulsion- 
Testing  the  Sterility  of  the  Emulsion — Preparing  the  Dilutions  .   514-517 
SUGGESTIONS  FOR  DOSAGE  OF  VACCINES        ......   517-518 

THE  DIAGNOSIS  OF  BACTERIAL  INFECTIONS   BY  MEANS  OF   THE  OPSONIC 

INDEX       ............  518-520 

TUBERCULIN  IN   DIAGNOSIS — von  Pirquet's   Reaction — Calmette's  Test — 

Subcutaneous  Injection     .........  520-522 

TUBERCULIN  IN  TREATMENT — The  Opsonic    Method — The  Use  of    Small 

Doses  at  Long  Intervals — The  Intensive  Method      ....  522-525 

INDEX 527-552 


ILLUSTRATIONS 

TO 

THE    FIRST    VOLUME. 


FIG.  PAGE 

1.  A   Leech  ...........         6 

2.  Method  of  applying  an  Ice-bag  .......         8 

3.  Leiter's  Tubes  ..........          9 

4.  Leiter's  Tubes  ..........        10 

5.  Wringer  for  Preparing  Fomentations  .          .          .          .          .          .12 

6.  Bier's  Suction  Apparatus  applied  to  the  Fore-arm         .  -14 

7.  Flat  Cautery .  .21 

8.  Gas  Stove  for  heating  Cauteries          .......       22 

9.  Constant  Irrigation  by  means  of  a  Strand  of  Worsted        ...        32 

10.  Constant  Irrigation   ..........        33 

1 1 .  Water-bath  for  Leg  .........       34 

12.  Water-bath  for  the  Hand  and  Forearm       .          .....        35 

13.  Method  of  Applying  a  Splint  to  the  Hand  and  Forearm  in  Cellulitis          .        36 

14.  The  Appearances  presented  by  a  Healing  Ulcer  .....        42 

15.  Method  of  Strapping  an  Ulcer     ........        48 

1 6.  Celluloid  Wound-shields     .          .          .          .          .          .  .          -52 

17.  Thiersch's  Method  of  Skin-grafting  (Cutting  the  grafts)  •          •          •       55 

18.  Thiersch's  Razor  for  Skin  grafting  ......       55 

19.  Thiersch's  Method  of  Skin-grafting  (The  graft  applied)  ....       56 

20.  Thiersch's  Method  of  Skin-grafting  (Applying  the  protective)  ...       57 

21.  Excision  of  a  Perforating  Ulcer  of  the  Foot         .....       65 

22.  Diagram  to  illustrate  the  Principles  of  Amputation  for  Gangrene  of  the  Leg       76 

23.  Glass  Jar  for  the  Sterilisation  of  Catheters  .....       92 

24.  High  Pressure  Steam  Steriliser     ........       97 

25.  Operating  Dress         ..........      103 

26.  Surgeon  wearing  Overall  and  combined  Cap  and  Mask  .          .          .      103 

27.  Esmarch's  Rubber  Tourniquet    ........      106 

28.  Crile's  Clamps  for  Temporary  Haemostasis  .  .....      108 

29.  Pressure  Forceps  for  Arrest  of  Haemorrhage          .          .          .          .          .109 

30.  Intra- venous  Infusion         .          .          .          .          .          .          .          •          .114 

31.  Diagram  to  Illustrate  the  Method  of  Continuous  Rectal  Infusion          .      115 

32.  Electrical  Apparatus  .          .          .          .          .          .          .          •          .116 

33.  Faulty  Method  of  Suturing  a  Wound  ....                          133 

34.  Anterior  View  of  the  Body  Illustrating  the  Directions  in  which  Incisions 

should  be  made       .......•••      J34 

35.  Posterior  View  of  the  Body  Illustrating  the  same  Point         .          .          .      135 

xix 


xx  ILLUSTRATIONS  TO 

FIG.  PAGE 

36.  A  Buried  Suture        .  .          .          .          .          .          .          .          -137 

37.  Halsted's  Intra-dermic  Suture  .          .......     137 

38.  Michel's  Clips 138 

39.  Removal  of  Michel's  Clips  by  Forceps          .          .          .          .          .          -138 

40.  Lister's  Needle  for  the  Introduction  of  Silver  Wire       ....      139 

41.  Method  of  Threading  Lister's  Needle  with  Silver  Wire         .          .          .139 

42.  Method  of  Suturing  a  Wound  where  there  is  much  Tension  on  the  Edges     141 

43.  Method  of  Inserting  the  Button-hole  Suture         .....      142 

44.  Methods  of  finishing  off  the  Button-hole  Suture  .          .          .          .143 

45.  Suture  of  an  Abdominal  Wound  in  Four  Layers  (First  layer)  .                144 

46.  Suture  of  an  Abdominal  Wound  in  Four  Layers  (Second  layer)        .          .145 

47.  Suture  of  an  Abdominal  Wound  in  Four  Layers  (Third  layer)         .          .146 

48.  Suture  of  an  Abdominal  Wound  in  Four  Layers  (Fourth  layer)        .          .147 

49.  Suture  of  the  Abdominal  Wall  in  Two  Layers      .          .          .          .          .148 

50.  Suture  of  Muscles  by  the  Mattress  Stitch  .          .          .          .          .149 

51.  Sizes  of  Drainage-Tubes     .........      150 

52.  Flushing  Curette          ..........      156 

53.  How  to  Fill  a  Quadrilateral  Defect  by  Means  of  a  Plastic  Operation     .      159 

54.  How  to  Fill  in  a  Triangular  Defect  by  Means  of  Plastic  Operation  .      159 

55.  How  to  Fill  in  a  Triangular  Defect  by  Means  of  Curved  Incisions        .      159 

56.  Kraske's  Treatment  for  Erysipelas  ......      199 

57.  Intra-cerebral  Injection  of  Anti-tetanic  Serum  .....      202 

58.  Apparatus  for  the  Intra-venous  Injection  of  '  Salvarsan  "...      214 

59.  Intra-venous  Infusion  of  'Salvarsan'          .          .          .          .          .          -215 

60.  Methods  of  inserting  the  Needles  in  Electrolysis  of  a  Nasvus  .          .257 

61.  Bipolar  Fork  Electrode  ....              ....      258 

62.  Compression  Forceps  for  Use  in  Electrolysis  of  Naevus  of  the  Lip  .      259 

63.  Method  of  Treating  Naevi  by  Compression  and  Electrolysis          .          .      260 

64.  Multiple  Naevi  in  Course  of  Treatment  by  the  Galvano-Cautery     .          .      261 

65.  Method  of  Applying  the  Solid  Stick  of  Carbon  Dioxide       .          .          .      262 

66.  Diagrams  to  illustrate  the  forms  of  Superfluous  Digits  .          .          .     268 

67.  Incisions  for  the  removal  of  a  Supernumerary  Thumb  .          .          .      269 

68.  Splint  for  the  after-treatment  of  Bifid  Finger        .          .          .          .          .270 

69.  Diagrams  to  illustrate  the  degrees  of  Webbed  Fingers  .          .          .271 

70.  The  Ear-ring  Perforation  Operation  for  Webbed  Fingers        .          .          .     272 

71.  The  V-shaped  Flap  Operation  for  Webbed  Fingers        .          .          .          .272 

72.  Didot's  Operation  for  Webbed  Fingers         ......     273 

73.  Splint  for  use  after  Didot's  Operation         ......      274 

74.  Hammer  Toe          ....  ......     276 

75.  Diagram  to  show  how  forcible  straightening  of  a  Hammer  Toe  may  result 

in  dislocation          ..........     276 

76.  T-Shaped  Splint  for  Hammer  Toe       .......      277 

77.  Splint  for  all  the  Toes        .........     278 

78.  Splint  for  use  in  After-treatment  of  Hammer  Toe         ....      278 

79.  Diagram  illustrating  the  Principles  to  be  observed  in  making  Boots       .      280 

80.  Diagram  showing  the  Relationship  of  the  Impression  of  the  Foot  to  the 

lines  which  bound  its  outline  .......      281 

81.  Diagram  to  illustrate  the  employment  of  a  '  Toe-post'          .          .          .     282 

82.  A  Method  of  improvising  a  Toe-post          ......     282 

83.  Bunion  Spring  ..........      283 

84.  Operation  for  Hallux  Valgus,  showing  the  Incision  through  the  Skin       .     284 

85.  The  Bones  of  the  Great  Toe  in  a  case  of  Hallux  Valgus       .          .          .     285 

86.  Dupuytren's    Contraction.      Splint   for      use    immediately   after    Sub- 

cutaneous Division  of  the  Fascia   .......     292 


THE  FIRST  VOLUME  xxi 

FIG.  PAGE 

87.  Dupuytren's  Contraction.     Splint  for  maintaining  full  extension  after 

Subcutaneous  Division  of  the  Fascia       ......  293 

88.  Evcision  of  the  Palmar  Fascia             ....                    .          .  294 

89.  The  V  Operation  for  Dupuytren's  Contraction 295 

90.  Operation  for  Contracted  Finger  after  a  Burn 296 

91.  Whitman's  Brace  (First  Stage)  ........  302 

92.  Whitman's  Brace  (Second  Stage)         .......  303 

93.  Whitman's  Brace  (Third  Stage)           .......  304 

94.  Whitman's  Brace  (Fourth  Stage)         .......  304 

95.  Whitman's  Brace  (Final  Stage)           .......  305 

96.  Boots  for  use  in  Flat  Foot        ........  306 

97.  Golding  Bird's  Apparatus  for  Flat  Foot  (The  sling  applied)            .          .  307 

98.  Golding  Bird's  Apparatus  for  Flat  Foot  (Apparatus  complete)        .          .  308 

99.  Whitman's  Apparatus  for  Intoeing     .         .          .          .          .          .          .311 

100.  Metal  Talipes  Splint 316 

101.  Splint  for  Talipes               .........  317 

102.  The  Methods  of  dividing  the  Tendo  Achillis  Subcutaneously          .          .  324 

103.  Diagram  showing  the  Structures  needing  Division  in  Talipes  Equino-varus  325 

104.  Sayre's  Apparatus  for  use  after  Tenotomy  of  the  Tendo  Achillis     .          .  327 

105.  Boot  for  use  after  Tenotomy  of  the  Tendo  Achillis       .          .          .          .328 

1 06.  Lines  of  Incision  for  Subcutaneous  Division  of  the  Plantar  Fascia         .  330 

107.  Excision  of  the  Astragalus        ........  331 

1 08.  Boot  for  use  after  Excision  of  the  Astragalus       .....  333 

109.  Boot  for  use  in  Talipes  Calcaneus                ......  336 

no.  Flap  Method  of  Exposing  the  Tendo  Achillis       .....  337 

in.  Oblique  Section  for  Shortening  Tendons               .....  337 

112.  "L-Shaped  Section  for  Shortening  Tendons         .....  338 

113.  Transplantation  of  the  Tendo  Achillis         ......  339 

114.  Boot  for  use  in  Talipes  Valgus           .......  343 

115.  Sayre's  Apparatus  for  Equino-Varus  .          .          .          .          .          -349 

1 1 6.  Thomas's  Wrench              .........  353 

117.  Scarpa's  Shoe           ..........  354 

1 1 8.  Cuneiform  Tarsectomy  for  Talipes  Equino-varus         ....  359 

119.  Method  of  Suturing  the  Wound  after  Cuneiform  Tarsectomy        .          .  360 

1 20.  Simple  Apparatus  for  Bow-leg            .......  366 

121.  Tracing  from  a  case  of  Curvature  of  the  lower  end  of  the  Tibia  treated 

by  Simple  Splinting       .........  367 

122.  Various  Forms  of  Osteotomy  of  the  Tibia  ......  368 

123.  Method  of  putting  up  the  Limb  after  Osteotomy  of  the  Tibia       .          .  369 

124.  Thomas's  Hip  Splint  adapted  for  use  in  Genu  Valgum        .          .          .  374 

125.  Splint  for  use  in  Genu  Valgum         .......  375 

126.  Various  Forms  of  Osteotomy  for  Genu  Valgum          ....  377 

127.  Incision  for  Macewen's  Osteotomy  for  Genu  Valgum          .          .          .  378 

128.  Method  of  holding  Macewen's  Osteotome     ......  379 

129.  Macewen's  Osteotome       .          .          .          .          .          .  '        .          .          .  380 

130.  Limb  put  up  in  splint  after  Osteotomy  for  Genu  Valgum      .          .          .  382 

131.  Outside  Irons  for  use  after  Operation  for  Genu  Valgum  in  Adults        .  382 

132.  Coxa  Vara        ...........  387 

133.  Extension  Apparatus  for  Coxa  Vara          ......  388 

134.  Extension  Apparatus  for  Coxa  Vara  applied       .....  389 

135.  Splint  for  use  in  Coxa  Vara       ........  390 

136.  Sub-trochanteric  Osteotomy  for  Coxa  Vara         .....  391 

137.  Lorenz's  Non-operative  Method  for  Congenital  Dislocation  of  the  Hip 

(First  Stage)         ..........     396 


xxii  ILLUSTRATIONS  TO  THE  FIRST  VOLUME 


FIG. 


138.  Lorenz's  Non-operative  Method  for  Congenital  Dislocation  of  the  Hip 

(Second  Stage)     .          .          .          .          .          .          .          .          .  397 

139.  Lorenz's  Non-operative  Method  for  Congenital  Dislocation  of  the  Hip 

(Third  Stage) 398 

140.  Incision  for  the  Operative  Treatment  of  Congenital  Dislocation  of  the 

Hip     ............      401 

141.  The  Examination  of  a  Suspected  Case  of  Scoliosis       .          .          .          .410 

142.  A  well-designed  Desk  and  Seat          .          .          .          .          .          .          .414 

143.  Sketch  showing  the   Influence  of  Exercises  upon  Posture  and  Chest 

Capacity  ..........     418 

144.  Scoliosis :    Postural  Treatment  .......     420 

145.  Postural  Treatment  for  all  forms  of  Scoliosis       .....     420 

146.  Dowd's  Machine  .........     421 

147.  '  Spinal  Brace '  for  Scoliosis       ........      422 

148-196.     Muscular  Exercises     ........       424-438 

197.  Nitrous  Oxide  Apparatus          ........     449 

198.  Paterson's  Nosepiece        .........     451 

199.  Hewitt's  '  Gas  and  Oxygen  '  Apparatus       ......     451 

200.  Clover's  Small  or  Portable  Ether  Apparatus       .....     453 

201.  Allis's  Inhaler         ..........     455 

202.  Clover's  Portable  Ether  Apparatus,  fitted  for  Nitrous  Oxide  and  Ether 

combined  .          .          .          .          .          .          .          .          .          .     457 

203.  Chloroform  Drop-Bottle  with  hollow  Stopper       .....     459 

204.  Towel  folded  for  Administration  of  Chloroform          ....     459 

205.  Schimmelbusch's  Inhaler  ........     460 

206.  Junker's  Inhaler  .........     461 

207.  Vernon-Harcourt  Inhaler  ........      463 

208.  Metal  Inhaler  for  Mixtures        ........     465 

209.  Metal  Inhaler  in  Section  ........     465 

210.  Chloride  of  Ethyl  Tube  ........     466 

211.  Mouth  Tube  of  Stout  Metal 468 

212.  Hahn's  Tracheotomy  Tampon  .......     469 

213.  Hahn's  Chloroform  Attachment         .......     469 

2*14-215.     Protection  of  Hair  in  Operations  in  that  Region      ....      470 

216.  Mouth  Gag  ..........     475 

217.  Tongue  Forceps       ..........     475 

218.  Metal  Bottle  containing  Anaestile       .......      482 

219.  Cocaine  Spray  for  Throat  and  Nose  Work         .....     483 

220.  Syringe  and  Needles  for  Spinal  Anaesthesia        .....     487 

221.  Thoma's  Haemocytometer          .          .          .          .          .          .          .          .491 

222.  The  Central  Disc  of  the  Counting  Chamber  of  Thoma's  Haemocytometer     493 

223.  Haldane's  Haemoglobinometer  .......     501 


DIVISION  I. 

INFLAMMATION 
AND    ITS    SEQUELS. 

CHAPTER  I. 
INFLAMMATION. 

DEFINITION". — Inflammation  may  be  denned  as  the  first  series  of 
changes  that  occur  in  a  tissue  as  the  result  of  an  injury,  provided  that 
the  latter  has  not  been  sufficiently  violent  to  destroy  the  vitality  of  the 
part  at  once.  When  an  injury  is  done  to  a  part,  whether  the  injury  be 
chemical  or  mechanical  in  nature,  a  certain  series  of  changes  at  once 
commences  there,  and  this  we  call  inflammation,  so  long  as  it  is  of 
an  exudative  or  destructive  character.  The  amount  of  inflammatory 
change  in  the  tissue  will  depend  upon  the  length  of  time  that  the  process 
lasts,  and  the  severity  and  result  of  the  inflammation  will  be  propor- 
tionate to  the  length  of  time  that  the  irritant  exerts  its  influence,  and 
the  intensity  with  which  it  acts.  Inflammation  is  divided  into  two 
forms — acute  and  chronic. 

ACUTE  INFLAMMATION. 

PATHOLOGY. — It  is  only  necessary  here  to  enumerate  the  changes 
that  take  place  in  the  tissues  after  an  injury. 

Changes  in  the  Early  Stages.— In  the  first  instance  they  consist 
of  dilatation  of  the  blood-vessels,  preceded  in  some  cases  by  contrac- 
tion. This  dilatation  chiefly  affects  the  small  arteries  and  capillaries, 
but  also  to  some  extent  the  veins.  The  circulation  of  the  blood  is 


2  INFLAMMATION   AND   ITS  SEQUELS 

quickened,  but  slowing  of  the  blood-stream  soon  becomes  evident,  and 
eventually  complete  stasis  or  coagulation  of  the  blood  takes  place  within 
the  vessels  at  the  focus  of  the  inflammation  in  severe  cases.  During 
this  period  also,  fluid  collects  in  the  surrounding  tissues,  which  become 
much  swollen.  Probably  this  fluid  is  mainly  derived  from  the  blood 
plasma,  but  in  part  it  is  lymph  retained  in  the  tissues.  Not  only  does 
fluid  accumulate  outside  the  vessels  and  coagulate  there,  but  the  white 
corpuscles  pass  out  through  the  walls  of  the  veins  in  large  numbers,  and 
also  to  some  extent  through  those  of  the  capillaries  ;  in  certain  inflamma- 
tions also,  red  blood-corpuscles  may  escape  from  the  blood-vessels.  The 
inflammatory  process  may  come  to  a  stop  at  this  stage,  if  the  cause  has 
ceased  to  act,  and  then  the  process  known  as  resolution  sets  in,  that  is 
to  say,  the  exuded  material  becomes  broken  up  and  removed  by  the 
lymphatic  vessels,  and  the  migrated  corpuscles  either  re-enter  the  blood- 
vessels or  the  lymphatics,  or  break  down  and  are  carried  away  in  the 
form  of  debris.  The  dilated  vessels  gradually  regain  their  tone,  and 
ultimately  the  part  resumes  its  normal  appearance  and  structure.  In 
very  severe  cases,  on  the  other  hand,  the  stasis  and  exudation  may  be 
so  great  as  to  lead  to  gangrene  of  the  part  even  at  this  early  stage. 

Changes  in  the  Later  Stages. — Inflammation  that  has  gone  on 
to  this  degree  generally  proceeds  further,  and  the  inflammatory  process 
gradually  brings  about  the  disappearance  of  the  original  tissue  which 
becomes  replaced  by  what  is  known  as  granulation  tissue,  composed,  in 
the  first  instance,  of  round  cells  and  embryonic  blood-vessels.  When 
this  stage  of  granulation  is  reached  one  of  three  things  will  happen.  In 
the  first  place,  the  irritant  may  cease  to  act,  in  which  case  the  inflamma- 
tory process  subsides  and  retrogressive  changes  take  place,  in  the  course 
of  which  the  cells  composing  the  granulation  tissue  develop  into  fibrous 
tissue,  and  the  blood-vessels  diminish  in  number  and  become  blocked 
by  a  process  analogous  to  arteritis  ;  the  ultimate  result  of  this  is  the 
formation  of  scar  tissue,  and  not  restoration  of  the  part  to  its  normal 
condition,  as  is  the  case  in  resolution.  In  the  second  place,  the  process 
may  end  in  suppuration  if  the  cause  of  the  inflammation  be  more 
persistent,  as  it  usually  is.  In  the  third  place,  the  result  known  as 
ulceration  may  follow,  when  the  inflammatory  process  affects  the  skin 
or  mucous  membrane,  and  is  not  very  violent. 

SYMPTOMS. — We  shall  consider  first  the  symptoms  of  the  early 
stage  ;  these  are  partly  local  and  partly  general.  The  local  changes  are 
diffuse  redness  of  the  part,  which  is  most  intense  at  the  centre,  and 
swelling,  which  varies  in  character  at  different  parts,  being  hard  and 
brawny  towards  the  centre  of  the  inflammatory  area  and  soft  and 
cedematous  towards  its  margins  and  which  sometimes  assumes  large 
proportions.  There  is  also  heat  and  severe  pain,  usually  of  a  throbbing 
character,  which  is  worse  when  the  inflammation  affects  dense  tissues 
and  when  the  part  assumes  the  dependent  position. 


ACUTE   INFLAMMATION  3 

When  the  inflammation  is  due  to  a  chemical  or  mechanical  irritant, 
the  symptoms  are  usually  entirely  local,  with  the  exception  of  such  slight 
constitutional  disturbance  as  may  be  caused  by  pain  and  sleepless- 
ness. When,  however,  the  local  irritation  is  produced  by  parasitic 
organisms,  there  are  usually  general  or  constitutional  symptoms  as  well. 
These  vary  considerably  in  degree ;  in  some  cases  they  are  trivial 
or  absent,  while  in  others  they  are  of  extreme  severity.  They  are 
marked  by  a  certain  amount  of  fever  and  present  two  great  types.  The 
first  type  is  commonly  termed  sthenic  fever,  and  in  it  there  is  headache 
and  anorexia,  the  temperature  rising  to  103°  or  104° ;  the  pulse  becomes 
rapid,  varying  from  100  to  112,  and  is  full,  not  easily  compressible,  but 
regular.  The  tongue  is  furred,  white,  and  moist,  the  skin  is  hot  and  dry, 
the  bowels  are  constipated,  and  the  urine  is  scanty  and  high-coloured. 
Delirium  of  a  noisy  and  violent  character  is  often  present ;  in  fact,  this 
form  of  inflammatory  fever  is  characteristic  of  strong  reaction,  and 
the  patient  shows  no  marked  depression.  The  second  type,  termed 
asthenic  inflammatory  fever,  is  met  with  in  certain  cases ;  the  great 
characteristic  of  this  type  is  marked  depression  of  the  vital  powers. 
The  temperature,  as  in  the  other  case,  is  high,  but  the  pulse  is  quicker 
and  may  run  up  to  130,  and  is  soft,  thready  and  easily  compressible. 
The  tongue  is  dry  and  brown,  delirium,  if  present,  is  of  a  low  mut- 
tering character,  and  the  patient  is  generally  in  a  semi-conscious  state. 
The  condition  of  the  patient  is  in  fact  due  to  an  acute  septic  poisoning 
(see  p.  189). 

TREATMENT. — This  is  best  considered  under  the  heads  of  local 
and  general  treatment.  The  great  characteristic  of  the  inflammatory 
changes  is  that  they  only  continue  as  long  as  the  cause  which  produces 
them  continues  to  act ;  as  soon  as  the  cause  ceases  to  act,  they  quickly 
come  to  a  standstill,  and  then  either  resolution  or  retrogression,  with  or 
without  scar-formation,  takes  place. 

Removal  of  the  Cause. — Hence,  the  first  great  question  in  the 
treatment  of  inflammation,  is  whether  it  is  possible  to  remove  the 
cause.  The  causes  of  inflammation  will  be  discussed  more  in  detail 
in  connection  with  suppuration ;  but,  as  regards  treatment,  they  may  be 
divided  into  two  classes — viz.  those  which  are  and  those  which  are  not 
readily  got  rid  of.  The  removable  causes  are  foreign  bodies,  chemical 
irritants,  and  the  like ;  the  irremovable  ones  are  micro-organisms  growing 
in  the  tissues,  and  they  are,  unfortunately,  the  more  common.  The 
action  of  these  parasites,  however,  is  to  a  certain  extent  dependent  upon, 
or  influenced  by,  various  circumstances  which  favour  their  growth.  There- 
fore, if  any  foreign  body  or  other  removable  cause  be  present,  it  should 
be  removed  and  if  there  be  no  cause  that  can  be  removed,  an  attempt 
should  be  made  to  put  the  tissues  under  the  most  favourable  conditions 
to  resist  the  growth  of  the  parasite,  and,  moreover,  anything  which  is 
aiding  its  development  should  be  got  rid  of  if  possible. 


4  INFLAMMATION   AND  ITS  SEQUELAE 

Local  Treatment. — The  most  obvious  symptom  in  inflammation 
is  the  congestion  of  the  part,  and  the  first  point  in  the^local  treatment  of 
an  acute  inflammatory  trouble  in  which  the  cause  is  irremovable,  is  to 
attempt  to  diminish  this  congestion  as  much  as  possible.  If  the  con- 
gestion be  diminished,  the  pain  will  be  lessened  also  and  the  patient's 
general  condition  ameliorated. 

Position. — When  an  inflamed  part  is  allowed  to  hang  down,  the 
throbbing  and  the  pain  increase,  as  a  result  of  the  dilatation  of  the  blood- 
vessels. The  first  essential  in  the  treatment  of  acute  inflammation, 
therefore,  is  to  raise  the  inflamed  part  and,  if  possible,  to  place  it  on  a 
higher  level  than  the  heart.  By  doing  this  the  congestion  is  diminished 
not  only  by  the  mechanical  emptying  of  the  blood-vessels,  but  also  by 
the  production  of  reflex  contraction  of  the  arteries. 

Blood-letting. — A  second  method,  by  which  the  congestion  of  the 
part  may  be  relieved  and  the  local  symptoms  considerably  ameliorated, 
is  blood-letting,  which  may  be  either  general  or  local. 

General  blood-letting,  or  the  removal  of  a  relatively  large  quantity 
of  blood  from  the  general  circulation  without  any  special  reference  to 
the  seat  of  the  inflammation,  probably  acts  by  lowering  the  action  of 
the  heart,  producing  faintness,  and  so  diminishing  the  circulation  in  the 
affected  part.  It  is  also  possible  that  the  loss  of  a  considerable  quantity 
of  blood  may  alter  the  constitution  of  the  remaining  blood  plasma  to 
some  extent,  and  render  it  more  active  as  an  anti-bacteric  agent.  General 
blood-letting  was  formerly  much  in  vogue,  but  is  seldom  practised  nowa- 
days ;  it  is  best  effected  by  opening  a  vein,  the  one  usually  chosen  being 
the  median  basilic,  on  account  of  its  large  size  and  ready  accessibility. 
The  method,  however,  at  the  present  time  is  almost  entirely  restricted  to 
such  inflammatory  conditions  of  the  lungs,  and  sometimes  of  the  brain, 
as  are  characterised  by  engorgement  of  the  right  side  of  the  heart. 

Although  this  is  a  small  operation,  it  is  absolutely  necessary  to  per- 
form it  with  full  antiseptic  precautions,  the  patient's  skin,  the  operator's 
hands,  and  the  lancet  being  thoroughly  purified  in  the  ordinary  manner  ;  i 
in  former  times  patients  occasionally  lost  their  lives  from  septic  throm- 
bosis. The  patient  sits  upright  upon  a  couch,  so  that  he  can  lie  down 
immediately,  should  he  feel  faint ;  this  position  has  the  further  advantage 
that  the  patient  will  become  faint  sooner  than  if  he  \vere  lying  down, 
and  thus  a  certain  safeguard  is  provided  against  the  withdrawal  of  too 
much  blood.  Venesection  should  never  be  practised  with  the  patient  in 
the  recumbent  position.  A  bandage  is  tied  in  a  bow  round  the  upper 
arm,  tight  enough  to  cause  engorgement  of  the  veins,  but  not  to  interfere 
with  the  arterial  flow.  The  superficial  veins  are  distended  still  further 
by  making  the  patient  grasp  a  stick,  which  helps  to  force  the  blood  from 
the  deep  into  the  superficial  veins.  The  surgeon  faces  the  patient,  grasps 

1  For  the  methods  of  disinfection  of  skin,  instruments,  etc.,  see  Chap.  V. 


ACUTE  INFLAMMATION  5 

the  arm  with  his  left  hand,  and  steadies  the  median  basilic  vein  by  placing 
the  left  thumb  upon  it  immediately  below  the  intended  seat  of  puncture  ; 
then,  with  a  sharp  double-edged  lancet,  he  makes  an  oblique  incision 
through  the  skin  and  the  anterior  wall  of  the  vein  at  one  cut.  The  incision 
should  cross  the  long  axis  of  the  vein  a  little  obliquely ;  the  posterior 
wall  of  the  vein  should  not  be  divided.  The  blood  flows  in  a  steady 
stream  from  the  vein,  and  is  received  into  a  graduated  porringer.  It  is 
generally  the  custom  to  slip  the  left  thumb  over  the  incision  in  the  vein 
as  soon  as  it  is  made,  so  as  to  prevent  bleeding  until  the  porringer  is  in 
position. 

The  amount  of  blood  usually  withdrawn  from  an  adult  varies  from 
ten  to  fifteen  ounces,  in  the  case  of  children  from  one  to  three.  In  former 
days  the  patient  was  bled  until  he  felt  faint  or  actually  fainted, 
but  bleeding  to  this  extent  is  practically  never  employed  at  the  present 
time.  After  a  sufficient  quantity  of  blood  has  been  withdrawn,  the 
bandage  around  the  arm  is  removed  and  a  small  pad  of  gauze  is  placed 
over  the  incision,  and  kept  in  position  by  a  few  turns  of  a  figure-of-eight 
bandage.  This  suffices  to  arrest  the  bleeding,  and  in  a  few  days  the 
wound  will  be  healed  and  the  circulation  re-established.  The  patient 
should  keep  the  arm  in  a  sling  for  four  or  five  days.  Modifications  in 
the  operative  technique  may  be  necessary  when  the  operation  is  per- 
formed in  cases  of  pneumonia,  heart  disease,  apoplexy  or  similar  condi- 
tions ;  here  the  position  of  the  patient  and  possibly  other  details  must 
be  arranged  to  meet  the  requirements  of  the  individual  case. 

The  operation  is  easy,  but  care  must  be  taken  not  to  allow  the  point 
of  the  lancet  to  penetrate  too  deeply,  for  the  brachial  artery  has  been 
punctured  and  an  aneurismal  varix  has  resulted.  A  vein  which  used 
to  be  frequently  opened  is  the  external  jugular  vein  as  it  crosses  the 
sterno-mastoid  muscle,  but  here  there  is  considerable  risk  of  air  entering 
the  vein  and  causing  serious  danger  to  life.  Moreover,  the  operation 
in  this  situation  possesses  no  countervailing  advantages  in  cases  of 
inflammation,  and  therefore  we  shall  not  describe  it. 

The  method  most  in  vogue  at  the  present  day,  however,  is  local 
blood-letting,  which  may  be  effected  by  the  application  of  leeches,  the 
use  of  cupping,  or  the  employment  of  incisions  or  scarifications. 

Several  points  require  to  be  mentioned  with  regard  to  the  application 
of  leeches.  The  part  to  which  the  leeches  are  to  be  applied  must  be 
carefully  cleansed,  as  otherwise  they  will  not  bite  readily ;  the  applica- 
tion of  a  little  cream  or  milk  to  the  skin  may  prove  effectual  in  making 
them  do  so.  When  the  leeches  are  put  on  the  skin  they  should  be  con- 
fined until  they  have  taken  hold,  and  this  may  be  conveniently  done  by 
inverting  over  them  a  pill-box  or  wineglass  of  suitable  size ;  when  they 
have  fixed  themselves  this  can  be  taken  away.  Special  leech-glasses  are 
employed  for  this  purpose,  and  answer  admirably ;  in  using  them  it  is 
necessary  to  see  that  the  leech  is  put  into  the  glass  tail  first  (the  thick 


INFLAMMATION  AND   ITS   SEQUEL.E 


end  of  the  leech)  and  not  head  first ;  the  mistake  is  not  uncommonly 
made  by  students.  A  narrow  test-tube  answers  the  purpose  of  a  leech- 
glass  excellently.  Leeches  that  have  not  been  confined  in  this  manner 
to  the  area  to  which  it  is  desired  to  apply  them  have  wandered  into 
mucous  canals,  such  as  the  rectum  or  the  vagina,  and  have  there  caused 
considerable  mischief. 

When  a  leech  has  been  applied,  it  is  allowed  to  suck  its  fill,  and 
the  amount  of  blood  which  each  individual  leech 
will  abstract  varies  from  a  drachm  to  a  drachm 
and  a  half.  When  it  has  sucked  as  much  blood 
as  it  will  hold,  it  usually  falls  off,  but  its 
detachment  can  always  be  hastened,  if  neces- 
sary, by  applying  salt  and  water  to  it.  The 
wound  made  by  the  leech  is  tri-radiate  and 
does  not  extend  deeply  into  the  skin,  and,  there- 
fore, were  there  no  provision  for  preventing  it, 
coagulation  would  occur,  and  very  little  blood 
would  be  obtained  from  the  wound  after  the 
leech  had  detached  itself.  In  the  pharynx  of  the 
leech,  however,  there  is  a  gland  secreting  a  sub- 
stance which  prevents  the  coagulation  of  the 
blood,  and  it  is  probable  that  the  cases  of 
troublesome  bleeding  after  the  application  of 
leeches  are  explained  by  the  fact  that  this  secre- 
tion has  been  left  in  the  wound  in  considerable 
quantity. 

Bleeding  from  LetchrlriUs. — As  a  rule,  bleeding 
from  a  leech-bite  stops  soon  after  the  leech  has 
been  removed;  in  many  cases  indeed,  fomenta- 
tions have  to  be  applied  when  it  is  desired  to 
abstract  more  blood.  Occasionally,  however, 
there  is  considerable  difficulty  in  arresting  the 
bleeding.  If  a  firmly  applied  pad  and  bandage  should  fail,  the  skin  around 
the  leech-bite  should  be  pinched  up,  the  bite  carefully  dried,  and  flexile 
collodion  painted  over  it  and  allowed  to  dry  before  the  pressure  is 
relaxed ;  or  a  solution  of  adrenalin  chloride  (i  in  1000)  may  be  applied  in 
a  similar  manner  and  is  very  efficacious.  Should  this  not  be  available, 
however,  liquor  fern  perchloridi  may  be  applied.  Should  the  bleeding 
persist  in  spite  of  this,  the  most  effectual  plan  is  to  excise  the  leech-bite 
and  suture  the  edges  of  the  wound  thus  made ;  the  object  is  to  remove 
the  tissues  impregnated  with  the  material  from  the  leech's  pharynx. 

In  view  of  the  possible  occurrence  of  troublesome  haemorrhage,  it  is 
not  advisable  to  apply  leeches  to  any  region  in  which  the  skin  cannot  be 
compressed  against  a  bone.  For  instance,  they  should  not  be  applied 
to  the  scrotum ;  if  leeching  be  required  for  an  inflammatory  condition 


FIG.  i.  —  A  LEECH. 
The  drawing  is  natural 
sice,  and  shows  the  T«H- 

tTi-     ^S^-f-^      :t      l-r     .rc^~. 

with  the  head  uppermost. 


ACUTE  INFLAMMATION  7 

in  that  situation,  the  leech  should  be  placed  on  one  side  of  the  perineum, 
where  pressure  can  be  applied  against  the  pubic  bone.  When  leeches 
are  required  for  affections  of  the  eye,  the  best  plan  is  to  apply  them 
over  the  temple  where  firm  pressure  can  be  easily  applied,  if  necessary. 
The  hair  should  be  shaved  from  the  spot  to  which  the  leech  is  to  be 
applied,  and  the  mark  of  the  bite  will  be  concealed  when  the  hair  grows 
again.  It  is  also  well  to  apply  leeches  early  in  the  day,  so  that  bleeding 
may  be  readily  observed,  as  serious  loss  of  blood  has  occurred  through 
unnoticed  continuous  oozing  through  the  night. 

Another  method  of  blood-letting  employed  in  inflammation  is 
cupping.  For  the  purpose  of  actually  removing  blood,  wet  cupping  is 
used,  but  in  some  cases  a  good  deal  of  benefit  is  derived  from  the  employ- 
ment of  Dry  Cupping,  which  consists  in  applying  the  cups  without  previous 
scarification  of  the  skin,  and  therefore  without  any  loss  of  blood  to  the 
patient.  If  the  special  cup  sold  for  the  purpose  be  not  available,  a  small 
tumbler  will  answer  equally  well.  The  edge  of  this  is  oiled,  and  a  piece 
of  blotting-paper,  dipped  in  methylated  spirit,  is  wedged  firmly  in  the 
bottom  of  the  glass,  and  set  on  fire  with  a  match ;  if  too  small  a  piece 
be  used,  it  may  fall  down  and  burn  the  patient's  skin.  When  the  paper 
has  burned  a  few  seconds  the  glass  is  inverted  over  the  skin,  which  should 
have  been  sponged  previously  with  warm  water ;  as  the  heated  air  in  the 
glass  contracts  on  cooling,  a  partial  vacuum  is  created,  and  the  skin  and 
subcutaneous  tissues  are  drawn  up  into  the  cup,  forming  a  prominent 
mass  full  of  blood.  Another  method  is  the  following:  the  edge  of  the 
cupping-glass  is  well  greased  and  a  few  drops  of  spirit  are  poured  into  it. 
This  is  then  lighted,  blown  out  and  relighted,  the  process  being  repeated 
until  the  vapour  lights  with  a  slight  explosion.  The  cup  with  the  lighted 
vapour  is  then  rapidly  applied,  the  flame  is  extinguished  instantly  and  the 
vacuum  formed.  A  number  of  cups  may  be  applied  in  this  way  and 
left  on  until  the  swelling  of  the  skin  has  increased  to  such  an  extent  as  to 
replace  the  air  lost  by  the  heat,  when  they  become  loose ;  should  it  be 
desired  to  remove  them  before  this  has  occurred,  it  can  be  easily  done 
by  insinuating  the  finger-nail  beneath  the  rim  of  the  cup,  so  as  to  allow 
the  entry  of  a  little  air. 

When  Wet  Cupping  is  employed,  the  skin  is  first  scarified  in  a  number 
of  places.  This  is  best  done  with  an  ordinary  scalpel,  as  the  special  in- 
strument sold  for  the  purpose  is  difficult  to  keep  aseptic  and  in  working 
order.  The  incisions  should  only  go  deep  enough  to  draw  a  little  blood  ; 
if  the  skin  be  cut  through  and  the  fat  exposed,  small  pellets  of  the  latter 
will  plug  the  incisions  and  stop  the  bleeding.  The  object  is  to  open  as 
large  a  number  of  capillaries  as  possible.  When  the  scarification  has 
been  done,  the  cup  is  applied  directly  over  the  scarified  area  as  already 
described.  The  result  is  that  blood  is  drawn  out  of  the  part  until  the 
place  of  the  air  is  taken  by  the  blood  which  issues  from  the  skin ;  the 
cup  then  gets  loose  and  can  be  removed.  If  required,  further  bleeding 


8 


INFLAMMATION  AND  ITS  SEQUEUE, 


can  be  promoted  by  the  application  of  warm  fomentations,  or  the  scarified 
surface  may  be  sponged  free  of  clots  and  the  cup  applied  a  second  or 
even  a  third  time  ;  the  quantity  removed  by  each  cup  is  from  one  to 
three  drachms.  The  method  is  especially  useful  in  the  lumbar  region, 
for  renal  affections.  There  is  no  trouble  in  arresting  the  bleeding. 

In  the  method  of  local  blood-letting  by  Scarifications  the  latter  are 
made  with  a  scalpel  with  the  precautions  already  referred  to  in  describing 
cupping.  Scarifications  are  mostly  used  in  cases  of  inflammation  affect- 
ing mucous  membranes,  such  as  inflammation  about  the  back  of  the 
throat ;  when  there  is  oedema  of  the  glottis  much  good  may  result  from 
early  scarification  of  the  pharynx  with  a  curved  bistoury  introduced 
through  the  mouth. 

Free  incisions  into  an  inflamed  part  are  often  of  great  value  in  acute 
inflammatory  conditions  j  they  not  only  allow  the  escape  of  blood  from 
the  engorged  blood-vessels,  but  also  permit  the  escape  of  the  exudation, 


FIG.  2. — METHOD  OF  APPLYING  AN  ICE-BAG. 

which  might  otherwise  cause  serious  pressure  upon  the  blood-vessels. 
This  is  more  especially  the  case  in  inflammations  in  dense  tissues,  such 
as  periosteum  and  bone,  where  the  blood-vessels  are  confined  within 
rigid  canals,  and  where  the  pressure  of  the  exudation  in  these  canals 
may  be  so  great  as  to  obliterate  the  vessels,  and  so  cut  off  the  blood- 
supply  to  the  bone.  In  early  acute  suppurative  periostitis  and  osteo- 
myelitis, it  is  imperative,  if  extensive  necrosis  is  to  be  avoided,  to  make 
free  incisions  through  the  periosteum  as  soon  as  the  nature  of  the  affection 
has  been  diagnosed,  and,  in  the  case  of  osteomyelitis,  to  remove  portions 
of  bone  so  as  to  open  up  the  medullary  cavity  freely. 

Cold. — The  local  inflammatory  phenomena  may  be  diminished  by  the 
application  of  cold,  which  is  supposed  to  act  by  contracting  the  arteries 
supplying  the  part,  and  so  diminishing  the  flow  of  blood  through  it. 
But  in  severe  inflammation,  the  vitality  of  the  tissues  may  be  so  depressed 
by  the  prolonged  application  of  cold,  that  actual  death  of  the  tissue  may 
follow,  and  this  is  a  danger  which  should  be  borne  in  mind.  Cold  also 
slows  the  circulation  so  that  the  blood  becomes  unduly  venous,  and 
thus  also  interferes  with  the  nutrition  of  the  part.  Hence  the  use  of 


ACUTE  INFLAMMATION  9 

cold  should  be  limited  to  the  early  stages  of  inflammation,  for  it  is  hardly 
likely  that  it  will  arrest  the  process  when  much  exudation  has  taken  place, 
while  in  this  stage  the  danger  of  weakening  the  tissue  is  especially  great. 
Probably  the  mildest  method  of  using  cold  is  in  the  form  of  an 
Evaporating  Lotion.^  A  piece  of  lint  is  placed  over  the  skin  and  kept 
constantly  moist  with  the  lotion,  the  part  being  freely  exposed  to  the 
air  to  favour  rapid  evaporation ;  the  patient  can  generally  keep  the  lint 
moist  for  himself.  Another  favourite  lotion  is  the  liquor  plumbi  sub- 


FIG.  3. — LEITER'S  TUBES.    The  illustration  shows  the  method  of  using  the  tubes  by 
coiling  them  in  a  spiral  manner  around  the  limb. 


acetatis  dilutus  (B.P.)  used  as  described  above.     If  there  be  much  pain, 
10  to  20  minims  of  tinct.  opii  may  be  added  to  each  ounce  of  this. 

If  greater  reduction  of  temperature  be  required,  dry  cold  should  be 
used,  because  the  wet  form  is  more  apt  to  lead  to  gangrene  than  is  the 
dry.  Dry  cold  may  be  applied  by  means  of  an  Ice-bag,  crushed  ice  being 
placed  in  an  indiarubber  bag  or  a  bladder  suspended  over  the  part  so 


1  The  following  may  be  found  useful : — 
Ammonii  chloridi        .      §ss.         Or, 
Spirit,  vini  rect.          .      §j. 
Aquam      .         .         ad   §viij. 
Misce.    Ft.  lotio. 


Ammonii  chloridi        .  3SS- 

Aceti  destillati  .  3J- 

Spiritus  rectificati        .  3J- 

Aquam        .          .       ad  5J- 
Misce.    Ft.  lotio. 


10 


INFLAMMATION  AND  ITS  SEQUEUE 


that  the  weight  of  the  ice  does  not  cause  pressure  upon  the  inflamed  area. 
A  convenient  plan  is  to  tie  the  ice-bag  to  a  bed-cradle,  so  that  it  just 
touches  the  part  where  cold  is  required.  A  piece  of  lint  should  be  placed 
between  the  ice-bag  and  the  skin  to  absorb  the  moisture  (see  Fig.  2). 
The  ice  will  require  renewal  as  it  melts,  and  therefore  the  bag  should  be 
inspected  frequently.  The  condition  of  the  part  should  be  carefully 
watched,  and  if  the  skin  become  dusky  from  excess  of  venous  blood,  or 
if  the  circulation  in  it  be  markedly  slowed — as  shown  by  pressing  on  the 
skin  and  watching  the  rapidity  with  which  the  vessels  fill  again — the  use 
of  cold  should  be  abandoned. 


FIG.  4. — LEITER'S  TUBES.  This  form  is  the  best  for  use  upon  most  occasions.  The 
tubes  are  coiled  upon  and  fixed  to  a  light  flexible  metal  plate,  and  hence  are  not  likely 
to  become  kinked  or  to  leak.  The  metal  plate  is  moulded  to  the  surface  and  secured 
by  tapes,  a  fold  of  lint  being  interposed  between  it  and  the  skin. 

A  still  more  effectual  way  of  employing  cold  is  by  means  of  Leiter's 
Tubes,  which  consist  of  fine  lead  tubing  twisted  into  a  flat  spiral  coil 
and  then  moulded  so  as  to  surround  the  part  without  causing  any  undue 
pressure.  Through  this  a  constant  stream  of  water  is  passed,  and  any 
required  degree  of  cold  can  be  obtained  according  to  the  temperature  of 
the  water.  Between  the  tubing  and  the  skin  a  piece  of  lint  should  be 
placed  (see  Figs.  3,  4). 

Intense  cold  may  be  produced  by  these  tubes,  and  it  is  seldom  advis- 
able to  leave  them  on  an  acutely  inflamed  part  for  more  than  twenty- 
four  hours  at  a  time.  The  condition  of  the  circulation  should  be  noted 
every  three  or  four  hours.  The  tubes  are  more  useful  for  arresting  bleed- 


ACUTE  INFLAMMATION  n 

ing  or  relieving  great  engorgement  of  the  part  than  they  are  in  inflamma- 
tion. When  used  for  the  latter  purpose,  the  temperature  of  the  water 
circulating  through  them  should  range  from  50°  to  60°  F.  ;  when  used  to 
arrest  bleeding,  the  temperature  may  be  as  low  as  33°  F. 

Heat. — When  an  acute  inflammation  has  lasted  for  two  or  three 
days,  cold  is  no  longer  of  benefit  and  may  even  cause  damage  ;  under 
these  circumstances  the  application  of  heat  is  more  likely  to  be  beneficial. 
It  soothes  the  inflamed  nerves,  causes  dilatation  of  the  vessels,  and,  by 
increasing  the  flow  of  blood,  brings  more  of  the  anti-bacteric  agents  into 
the  part. 

Heat  may  be  applied  to  the  skin  over  an  inflamed  part,  by  means  of 
poultices  or  hot  fomentations.  A  poultice  is  usually  made  with  about 
four  tablespoonfuls  of  linseed  meal  to  half  a  pint  of  water.  It  must  not 
be  too  heavy  and,  as  it  loses  its  heat  very  quickly,  special  care  should  be 
taken  to  see  that  the  bowl  in  which  it  is  mixed,  and  the  material  on  which 
it  is  spread,  are  well  warmed  previous  to  use.  The  poultice  should  be 
made  as  quickly  as  possible,  and  applied  as  hot  as  the  patient  can  bear 
it.  The  linseed  meal  is  well  stirred  into  the  boiling  water  so  as  to  ensure 
that  it  is  of  a  soft  even  consistency  free  from  hard  lumps  or  masses. 
When  mixed,  the  mass  is  turned  out  upon  a  piece  of  linen,  previously 
warmed,  and  large  enough  to  extend  two  inches  all  round  beyond  the 
poultice,  and  upon  this  it  is  spread  with  a  spatula  in  an  even  layer 
about  half  an  inch  thick.  The  edges  of  the  linen  are  then  turned  up 
around  the  margins  and  the  poultice  is  ready  for  use.  The  whole  opera- 
tion should  be  carried  on  before  a  good  fire.  After  the  poultice  has  been 
applied,  a  layer  of  well-warmed  wool  is  placed  outside  it,  and  the  whole 
is  fixed  on  with  a  bandage,  A  poultice  generally  retains  its  heat  for 
about  two  hours,  and  should  then  be  changed ;  when  it  is  removed,  the 
skin  should  be  dried  and  gently  chafed  with  a  soft  warm  towel,  and 
covered  with  a  blanket  until  the  fresh  poultice  is  ready.  Unless  the  pre- 
caution of  covering  up  the  patient  be  taken,  the  part  becomes  chilled,  and 
all  the  good  of  the  poultice  may  be  undone. 

There  are  various  advantages  and  disadvantages  in  the  use  of  poul- 
tices as  compared  with  fomentations.  Poultices  retain  the  heat  longer, 
and  therefore  it  is  not  necessary  to  change  them  so  frequently  as  fomenta- 
tions, while,  on  the  whole,  they  are  considerably  warmer.  The  chief 
objection  to  their  use  arises  in  connection  with  cases  in  which  a  surgical 
operation  will  be  necessary  subsequently.  It  is  difficult  to  purify  the 
skin  effectually  after  a  poultice  has  been  used,  for  the  latter  is  a  decom- 
posing vegetable  substance,  which  soaks  into  the  hair  follicles,  the  hairs, 
and  the  epidermis.  Hence,  when  an  abscess  is  likely  to  form,  and  when 
surgical  interference  may  therefore  be  required,  it  is  well  to  employ 
fomentations  instead  of  poultices.  Various  antiseptics  have  been  mixed 
with  the  poultice  in  order  to  render  it  aseptic.  Charcoal,  which  is  some- 
times employed,  is  simply  a  deodorant,  and  possesses  no  true  antiseptic 


12 


INFLAMMATION  AND  ITS  SEQUELS 


properties.  Boric  acid  or  carbolic  acid  is  also  sometimes  mixed  with  the 
poultice.  Probably  the  best  mixture  is  one  of  linseed  meal  and  eucalyptus 
oil,  but  none  of  them  are  satisfactory  from  the  antiseptic  point  of  view, 
and  hence,  when  an  operation  is  likely  to  be  required,  fomentations  should 
be  substituted  for  poultices,  at  any  rate  for  some  time  beforehand. 

When  making  fomentations,  the  precautions  against  loss  of  heat  must 
be  attended  to  even  more  carefully  than  in  the  case  of  poultices.  A 
fomentation  consists  of  a  piece  of  flannel  wrung  out  of  boiling  water  and 
covered  with  mackintosh  and  a  mass  of  wool,  and  the  great  point  in 
its  preparation  is  to  apply  it  as  hot  as  possible.  A  mass  of  wool 
considerably  larger  than  the  flannel  should  be  placed  in  readiness  before 
a  brisk  fire,  and  on  the  top  of  that  should  be  placed  a  piece  of  mackintosh 
with  the  mackintosh  side  outwards,  and  large  enough  to  overlap  the 
flannel  in  all  directions.  A  well-warmed  basin  is  then  taken,  a  dry 
towel  is  placed  over  it,  and  in  the  centre  of  this  towel  a  piece  of  flannel  of 

suitable  size  folded  in  two  or 
four  thicknesses  is  laid.  Boil- 
ing  water  is  poured  over  the 
flannel,  which  is  then  squeezed 
as  dry  as  possible  by  twisting 
up  the  ends  of  the  towel 
rapidly  ;  no  water  must  be 
left  in  the  flannel  lest  the 
patient  be  scalded.  The 
folded  flannel  is  then  quickly 
shaken  out  and  placed  on  the 
top  of  the  mackintosh,  and 

FIG.    5.-WRINGER   FOR    PREPARING   FOMENTATIONS.  ^Cn      ^6      Whole      HiaSS—  WOOl, 


mackintosh,     and    flannel  —  is 

lifted  up  and  applied  rapidly  to  the  affected  part.  As  soon  as  the 
patient  can  bear  it,  the  whole  is  fixed  on  with  a  binder  or  bandage. 
When  a  number  of  fomentations  have  to  be  applied  the  apparatus 
shown  in  Fig.  5  is  very  convenient.  It  consists  of  a  short  jack- 
towel  slung  on  two  pieces  of  broomstick.  The  flannel  is  placed 
between  the  two  layers  of  the  towel,  and  the  sticks  brought  together 
so  that  the  towel  and  flannel  hangs  down  between  them  and  can  be  dipped 
in  boiling  water.  By  twisting  the  sticks  in  opposite  directions  the  flannel 
can  be  wrung  out  very  thoroughly.  The  fomentation  will  usually  require 
to  be  renewed  in  from  half  an  hour  to  an  hour,  but  it  may  be  kept  warm 
longer  by  placing  an  indiarubber  hot-water  bottle  outside  it,  if  the  patient 
can  bear  the  pressure.  When  renewing  the  fomentations,  a  warm  towel 
must  be  at  hand,  with  which  the  skin  is  at  once  dried  and  chafed  when 
the  fomentation  is  taken  away,  and  this  towel  is  left  in  situ  while  the 
fresh  one  is  being  prepared.  When  there  is  severe  pain,  much  relief 
may  be  afforded  by  sprinkling  half  a  drachm  or  more  of  laudanum  on 


ACUTE  INFLAMMATION  13 

the  surface  of  the  fomentation  after  it  has  been  prepared ;  the  laudanum 
should  be  previously  warmed  by  immersing  the  bottle  in  hot  water. 
When  the  inflammation  is  deep-seated,  and  a  certain  amount  of  irritation 
of  the  skin  is  desired,  this  may  be  obtained  by  sprinkling  ten  to  twenty 
drops  of  turpentine  over  the  surface  of  the  flannel,  and  thus  making 
what  is  known  as  a  turpentine  stupe.  Antiphlogistine  is  a  very  satisfac- 
tory substitute  for  a  fomentation  in  some  cases. 

A  special  material,  known  as  spongiopilin,  is  sold  to  take  the  place 
of  mackintosh  in  the  fomentation.  It  consists  of  thick  felt  covered  on 
one  side  with  an  impermeable  layer,  and  is  employed  in  the  same  way 
as  the  flannel  in  making  the  fomentation.  As  a  rule,  however,  it  is  well 
to  place  mackintosh  and  wool  outside  the  spongiopilin,  as  in  an  ordinary 
fomentation. 

Bier's  Treatment. — Recently  a  method  of  treatment  has  been 
introduced  by  Prof.  Bier  of  Berlin,  which  is  of  great  help  in  suitable 
cases.  The  essential  point  in  Bier's  treatment  consists  in  the  production 
of  a  localised  hyperaemia.  This  may  be  obtained  in  several  ways,  and 
is  either  venous  (passive)  congestion,  arterial  (active)  congestion,  or  a 
combination  of  both. 

In  the  first  of  these — the  method  of  passive  congestion — an  elastic 
bandage  is  applied  between  the  inflamed  part  and  the  heart,  sufficiently 
firmly  to  impede  the  venous  circulation  without  affecting  the  arterial  to 
any  appreciable  extent.  The  bandage  employed  is  of  thin  indiarubber 
about  two  inches  wide,  and  in  some  cases  is  applied  next  to  the  skin. 
In  many  instances,  however,  it  will  be  found  advisable  to  surround  the 
part  with  wool  or  lint  before  applying  the  bandage,  so  as  to  avoid  injury 
to  the  skin  from  pressure.  When  the  bandage  has  been  properly  applied, 
the  parts  beyond  become  purplish  in  tint,  and  the  superficial  veins  are 
engorged ;  the  bandage  should  never  be  so  tight  as  to  cause  pain.  Cases 
are  described  in  which  the  limb  beyond  the  bandage  has  become  white 
and  cedematous — a  condition  known  as  white  stasis — but  this  indicates 
either  that  the  bandage  has  been  improperly  applied,  or  that  the  case  is 
unsuitable  for  this  treatment.  This  method  of  procuring  passive  conges- 
tion is  only  applicable  to  the  limbs.  In  the  case  of  the  shoulder- joint  a 
special  arrangement  must  be  employed.  It  has  not  been  found  possible 
to  treat  the  hip- joint  by  this  method. 

The  second  plan — the  method  of  arterial  congestion — is  carried  out  by 
directing  a  stream  of  hot  air  on  the  part,  or  by  the  application  of  local 
hot-air  baths.  For  the  latter  method,  a  number  of  specially  constructed 
chambers  with  heating  arrangements  have  been  devised.  The  result  is 
much  the  same  whether  these  be  heated  by  electric  lamps,  by  a  coil  of  wire 
with  a  high  electrical  resistance,  or  by  gas  or  oil-flames,  and,  apart  from 
the  question  of  price  and  convenience,  there  is  little  to  choose  between 
the  many  forms  of  apparatus  on  the  market.  The  hot-air  bath  is  adminis- 
tered daily,  the  temperature  employed  being  often  200°  F.  or  even  more. 


14  INFLAMMATION  AND  ITS  SEQUELAE 

The  bath  usually  lasts  from  half  an  hour  to  one  hour.     In  all  probability, 
poultices  and  hot  fomentations  act  in  the  same  way  as  this  method. 

Combined  arterial  and  venous  hypercemia  may  be  produced  by  the 
suction  method,  in  which  the  affected  part  is  placed  in  a  partial  vacuum. 
This  is  usually  effected  by  means  of  a  glass  vessel  joined  to  the  limb  bv 
a  tight  indiarubber  collar,  and  exhausted — either  by  an  ordinary  air-pump 
or  by  a  syringe — until  a  vacuum  equal  to  two  inches  of  mercury  is  pro- 
duced. The  suction  method  has  distinct  advantage  in  some  cases ; 
for  example,  in  dealing  with  sinuses,  not  only  is  congestion  produced,  but 
the  pus  is  removed  efficiently  (see  Fig.  6).  The  actual  details  of  the 
application  of  the  method  to  special  cases  will  be  explained  in  connection 
with  the  diseases  in  question.  The  mode  of  action  of  Bier's  treatment  is 
not  quite  clear,  but  the  most  recent  view  is  that  by  increasing  the  circula- 
tion of  blood  and  lymph  in  the  part,  it  floods  the  latter  with  serum 


FIG.  6. — BIER'S  SUCTION  APPARATUS  APPLIED  TO  THE  FORE-ARM.  The  limb 
is  placed  inside  the  glass  vessel  and  an  air-tight  junction  is  made  by  means  of  a 
rubber  collar.  The  air  is  then  exhausted  through  the  tube. 

containing  opsonins,  which  render  the  bacteria  vulnerable  to  the  phago- 
cytic  elements  of  the  body. 

General  Treatment. — This  should  be  directed  partly  to  relieving 
symptoms  such  as  pain,  and  partly  to  promoting  the  excretion  of  the 
toxins  absorbed  into  the  blood  from  the  inflamed  area.  With  the  latter 
object  attempts  are  made  to  dilute  the  toxins  in  the  blood  by  giving 
diluent  drinks,  and  also  to  assist  the  secretions  from  the  skin,  the  bowels, 
and  the  kidneys. 

Purgatives. — In  a  case  of  inflammatory  fever,  it  is  important  to 
administer  a  purge  without  delay ;  among  the  best  is  sulphate  of  magnesia 
or  some  other  saline.  Half  an  ounce  or  more  of  the  sulphate  of  magnesia 
is  given  dissolved  in  a  little  water  ;  the  more  concentrated  the  solution 
is  the  better  is  its  effect.  At  least  one  copious  watery  evacuation  daily 
should  be  thus  ensured.  The  purge  clears  out  decomposing  material  from 
the  intestine,  and  should  be  given  even  when  the  bowels  have  been  pre- 
viously acting  quite  regularly.  It  also  causes  transudation  of  a  quantity 
of  water  from  the  blood,  and  thus  possibly  removes  a  certain  amount  of 
the  toxins.  At  the  same  time,  it  probably  acts  also  as  a  counter-irritant, 
and  thus  exerts  a  further  beneficial  effect. 


ACUTE  INFLAMMATION  15 

Drinks. — The  patient  should  drink  large  quantities  of  fluid,  with  the 
view  of  diluting  the  poison  in  the  blood,  and  of  promoting  its  rapid 
elimination  by  the  kidneys.  Four  to  six  pints  of  milk  should  be  given 
daily  if  the  patient  can  take  it.  The  combination  of  milk  with  barley- 
water  is  good,  as  the  latter  prevents  to  some  extent  the  constipating 
effects  of  the  milk ;  it  also  retards  coagulation.  If  the  milk  curdles  in  the 
stomach,  lime-water  may  be  added,  or  still  better,  one-half  to  one  drachm 
of  the  liquor  calcis  saccharatus  to  each  tumblerful  of  milk.  The  patient 
should  be  also  encouraged  to  take  fluid  drinks  containing  bicarbonate  of 
potash  or  spirit  of  nitrous  ether.i 

These  methods  cause  the  kidneys  to  act  without  any  undue  irritation. 
Irritating  diuretics  must  be  carefully  avoided  on  account  of  the  tendency 
to  albuminuria  and  nephritis  in  many  of  these  acute  inflammatory 
affections. 

Drugs. — Drugs  are  of  little  advantage  at  this  stage,  but  at  night 
Dover's  powder  (gr.  10)  may  be  given,  partly  to  obtain  sleep  and  freedom 
from  pain,  but  mainly  to  promote  the  action  of  the  skin.  The  latter 
object  may  also  be  furthered  by  giving  liquor  ammonias  acetatis  in  two- 
to  four-drachm  doses  every  three  or  four  hours. 

Food. — The  food  should  be  fluid,  essentially  milk,  with  beef-tea  occa- 
sionally ;  it  is  well  to  administer  the  food  about  every  two  hours — a 
tumblerful  of  milk  alternating  with  a  cup  of  beef-tea  or  some  form  of  meat 
extract.  An  excellent  nutritive  broth  can  be  made  by  adding  to  each 
cupful  of  bouillon  a  teaspoonful  of  finely  grated  meat.  During  the  period 
of  recovery,  nourishing  diet  should  be  given,  with  stimulants  and  tonics, 
especially  iron. 

PROGNOSIS. — The  prognosis  of  acute  inflammation  depends 
on  its  nature  and  seat.  Should  an  acute  inflammation,  of  the  degree  of 
which  we  have  been  speaking,  last  for  more  than  three  or  four  days, 
suppuration  will  almost  certainly  take  place.  If,  on  the  other  hand,  the 
inflammation  be  subsiding,  wrinkling  of  the  skin  will  be  noticed,  and 
when  this  occurs,  a  favourable  prognosis  as  regards  suppuration  may  be 
given.  This  is  not  invariably  the  case,  since  wrinkling  of  the  skin  may 
be  met  with  in  the  vicinity  of  an  abscess,  owing  to  the  subsidence  of  the 
oedema. 

1  A  very  good  one  is  that  used  in  most  hospitals,  and  called  '  imperial  drink  '  ; 
it  consists  of  one  to  one  and  a  half  drachms  of  cream  of  tartar  added  to  a  pint 
of  boiling  water,  and  then  allowed  to  cool,  a  little  sugar  being  added  to  sweeten  it. 
The  cream  of  tartar  may  also  be  conveniently  given  in  gruel,  made  by  adding  a 
tablespoonful  of  oatmeal  and  about  a  drachm  of  cream  of  tartar  to  half  a  point  of 
water,  and  boiling  it,  adding  afterwards  a  tablespoonful  of  brandy  and  a  little  sugar. 
Another  excellent  diuretic  drink  can  be  made  by  adding  half  an  ounce  of  phosphate 
of  soda  to  an  ounce  of  water  flavoured  with  a  little  lemon-juice. 


16  INFLAMMATION  AND  ITS  SEQUELS 


CHRONIC    INFLAMMATION. 

PATHOLOGY. — The  process  of  chronic  inflammation  is  some- 
what difficult  to  understand  and  explain,  because  it  generally  forms 
a  part  of  some  other  morbid  process,  and  it  is  not  easy  to  separate  one 
from  the  other.  It  may  begin  as  an  acute  inflammation,  in  which  the 
symptoms  do  not  entirely  disappear,  but  gradually  become  less  acute  until 
the  affection  passes  into  the  chronic  form ;  on  the  other  hand,  the  inflam- 
mation may  be  chronic  from  the  commencement.  The  essential  feature 
in  chronic  inflammation  is  the  predominance  of  changes  in  the  cellular 
tissues  over  those  in  the  vascular  and  lymphatic  channels  which  are  ob- 
served in  acute  inflammation.  In  addition  to  the  increased  vascularity 
of  the  part  similar  to  that  seen  in  acute  inflammation,  a  tissue  which  is 
the  seat  of  chronic  inflammation  contains  in  abundance  cells  derived  not 
only  from  the  blood  itself,  but  also  by  a  process  of  multiplication  from 
the  endothelium  of  the  blood-vessels,  lymphatic  vessels,  and  in  part  from 
the  fixed  connective-tissue  cells  themselves.  These  cells — fibroblasts, 
plasma-cells,  mast -cells — all  contribute  to  the  formation  of  young  fibrous 
tissue,  which  may  be  collected  into  one  scar-like  mass,  or  may  be  spread 
out  between  the  cells  of  an  organ — such  as  a  gland — where  they  may  cause 
destruction  of  the  cells  of  that  organ  by  a  process  of  mechanical  compres- 
sion and  deprivation  of  blood.  The  latter  type  of  chronic  inflammation, 
which  is  well  seen  in  the  syphilitic  affections  of  the  liver  and  testis,  is 
known  as  fibrosis.  The  presence  of  these  cells  affords  valuable  aid  in 
distinguishing  between  inflammatory  and  malignant  growths,  as  they 
stain  very  characteristically  by  methods  such  as  that  of  Pappenheim 
(see  p.  1 8). 

A  chronically  inflamed  tissue  never  undergoes  suppuration  of  itself. 
The  so-called  suppuration  occurring  in  a  part  which  is  the  seat  of  chronic 
inflammation  is  due  either  to  acute  septic  infection,  or  to  the  liquefaction 
of  the  morbid  material  which  is  causing  the  inflammation  ;  the  latter  is 
especially  the  case  in  tubercle.  A  typical  chronic  abscess,  which  has  not 
been  acute  at  the  commencement,  is  practically  always  tuberculous. 

CAUSES. — Like  the  acute  form,  chronic  inflammation  depends 
upon  the  continued  action  of  some  exciting  cause,  but  the  causes  which 
produce  chronic  inflammation  are  not  of  the  same  violent  nature  as  those 
which  set  up  the  acute  form. 

The  most  common  cause  of  chronic  inflammation  is  the  presence  in 
the  tissues  of  some  morbid  material,  such  as  the  specific  virus  of  one  of 
the  chronic  infective  diseases — notably,  tubercle  and  syphilis  ;  and  it  is 
well  to  bear  in  mind  that  in  these  cases,  especially  in  tubercle,  the  main 
part  of  the  swelling  in  the  affected  area  is  due  not  to  the  mass  of 
tuberculous  tissue,  but  to  the  chronic  inflammation  which  its  presence 
has  set  up. 


CHRONIC  INFLAMMATION  17 

Among  other  causes  of  chronic  inflammation  may  be  mentioned  the 
presence  of  a  foreign  body ;  for  example,  a  bullet  embedded  in  the 
tissues,  provided  that  it  has  not  carried  in  with  it  any  pyogenic  organisms, 
will  set  up  chronic  inflammation  in  the  part,  which  may  last  for  a  con- 
siderable time  after  the  lodgment  of  the  foreign  body.  Any  obstruction 
to  the  free  exit  of  secretion  from  a  gland,  as  for  instance  a  stricture  or  a 
calculus  in  its  duct,  brings  about  retention  of  the  secretion  behind  the 
obstruction,  and  this  leads  to  a  chronic  inflammation  in  the  gland,  which 
will  continue  until  the  obstruction  is  relieved,  or  until  the  gland 
undergoes  atrophy ;  these  cases,  however,  are  often  complicated  by 
the  presence  of  a  mild  septic  infection.  Chronic  inflammation  not  infre- 
quently results  also  from  pressure,  and  ends  in  the  formation  of  a  quantity 
of  new  tissue,  as  is  seen  for  example  in  callosities,  which,  forming  in  a 
part,  subject  it  to  much  pressure.  Then,  again,  various  deposits  from 
the  blood  are  responsible  for  exciting  a  state  of  chronic  inflammation ; 
for  example,  in  gout  the  deposition  of  urates  in  the  tissues  keeps  up  a 
condition  of  chronic  inflammation  in  the  neighbourhood  of  the  deposit. 
In  some  cases,  chronic  inflammation  seems  to  be  dependent  on  certain 
states  of  the  blood,  the  precise  nature  of  which  is  not  evident ;  an  example 
of  this  is  seen  in  rheumatism,  where  chronic  inflammation  of  fibrous 
tissues  often  occurs,  and  may  continue  for  a  long  time. 

SYMPTOMS. — The  most  characteristic  symptom  of  chronic  in- 
flammation is  the  presence  of  swelling,  which  is  due  to  the  formation  of 
new  connective  tissue  ;  thus,  for  example,  a  bone  which  is  the  seat  of 
chronic  inflammation  may  become  enormously  thickened.  In  organs 
in  which  there  is  much  soft  tissue,  such  as  the  liver,  the  final  result  of  a 
chronic  inflammation  may  be  actual  diminution  in  size,  the  new  con- 
nective tissue  formed  undergoing  contraction,  and  leading  to  atrophy 
of  the  normal  cells.  In  most  cases,  however,  swelling  is  a  prominent 
feature.  Of  the  other  symptoms,  the  pain  varies  with  the  situation  and 
is  often  slight,  although  in  bone  it  is  a  marked  feature,  owing  to  the 
compression  of  the  nerves  by  the  exudation  in  the  unyielding  tissues. 
Some  tenderness  and  heat  are  almost  always  present.  The  increased 
vascularity  of  the  tissue  is  often  evidenced  by  the  enlargement  of  the 
veins  on  the  surface  of  the  swollen  part.  Constitutional  symptoms 
are  not  present  as  a  rule ;  if  they  are,  it  is  either  because  some  vital 
organ  is  affected,  or  because  they  are  due  to  the  disease  which  is  setting 
up  the  inflammation. 

In  many  cases  the  diagnosis  can  be  cleared  up  by  the  microscopical 
examination  of  an  excised  fragment  of  the  swelling.  The  presence  of 
cells,  such  as  Unna's  plasma-cells,  in  considerable  numbers  is  highly 
suggestive  of  the  inflammatory  nature  of  the  swelling.  Plasma-cells 
occur  in  normal  connective  tissue  and  to  a  certain  extent  in  the 
stroma  of  malignant  growths,  but  usually  only  in  comparatively  small 
numbers,  and  in  these  cases  their  presence  or  absence  should  always 
i.  c 


i8  INFLAMMATION  AND  ITS  SEQUELS 

be  ascertained  by  staining  by  Pappenheim's  1  or  some  allied  method. 
None  the  less,  the  microscopical  diagnosis  between  an  inflammatory 
swelling  and  a  new  growth  is  often  extremely  difficult  to  make. 

TREATMENT. — The  first  point  in  the  treatment  of  chronic 
inflammation  is  to  ascertain  whether  or  not  we  can  remove  the  cause, 
for  if  this  be  done  effectually,  the  inflammation  will  subside  at  once. 
Thus,  when  a  foreign  body,  such  as  "a  bullet,  is  embedded  in  the 
tissues,  the  indication  is  to  cut  down  and  remove  it.  Similarly,  when 
the  chronic  inflammation  is  caused  by  obstruction  of  a  duct,  this  must 
be  remedied ;  when  it  is  due  to  a  deposit  from  the  blood,  as  in  gout, 
or  to  some  state  of  the  blood,  as  in  rheumatism,  appropriate  medicinal 
treatment  must  be  adopted  for  the  elimination  of  the  noxious  material 
from  the  circulation.  Most  commonly,  however,  the  cause  of  the 
inflammation  is  the  presence  of  some  chronic  infective  disease,  and  it 
is  not  always  easy  to  get  rid  of  this  completely,  especially  when  it  is 
of  a  tuberculous  nature.  When  it  is  not  possible  or  advisable  to  remove 
the  cause,  various  measures  must  be  adopted  which  are  calculated  to 
diminish  the  inflammation ;  these  measures  are  essentially  local. 

Local  Treatment. — Rest. — The  first  essential  point  in  the  local 
treatment,  after  the  question  of  removal  of  the  primary  cause,  is  to 
secure  complete  physiological  rest  of  the  part,  and  this  is  absolutely 
necessary  for  the  subsidence  of  the  inflammation.  If  the  seat  of  the 
inflammation  be  a  joint,  this  should  be  fixed  ;  if  it  be  a  part  affected  by 
muscular  movements,  rest  must  also  be  obtained,  the  patient,  if  possible, 
being  in  bed  with  the  part  elevated.  It  has  already  been  pointed  out 
that  the  position  of  the  part  affects  the  congestion,  and  in  chronic  as  in 
acute  inflammation,  relief  of  the  congestion  by  means  of  the  elevated 
position  is  an  essential  element  in  treatment.  Even  when  it  is  im- 
possible to  remove  the  exciting  cause  (e.g.  tubercle),  much  good  may  be 
done  by  methods  calculated  to  diminish  the  inflammation  itself,  because 
inflamed  tissues  are  more  easily  invaded  by  the  morbid  process  than 
healthy  ones  ;  if  the  chronic  inflammation  can  be  diminished,  extension 
of  the  primary  disease  may  thereby  be  checked. 

Counter-irritation. — By  counter-irritation  is  meant  the  application 

1  The  stain  should  be  prepared  fresh :  a  convenient  method  is  the  following. 
The  dry  stain  is  picked  up  on  the  point  of  an  ordinary  small  blade  of  a  pen-knife 
so  as  to  cover  about  a  quarter  of  an  inch  of  the  blade.  Four  times  this  quantity  of 
pyronin  and  twice  the  quantity  of  methyl-green  are  dissolved  in  half  a  test-tube 
of  distilled  water,  boiled  and  filtered  hot  on  to  the  section.  The  stain  is  allowed  to 
act  for  five  minutes.  A  ten-per-cent.  alcoholic  solution  of  resorcin  is  then  poured 
on  to  act  as  a  mordant,  the  excess  stain  is  removed  from  the  section  by  absolute 
alcohol  and  the  specimen  is  cleared  in  xylol  and  mounted  in  Canada  balsam.  The 
degree  of  differentiation  can  be  watched  conveniently  while  the  specimen  is  in 
xylol,  and  if  it  is  incomplete  more  alcohol  can  be  used.  The  purple  nuclei  of  the 
plasma-cells  and  their  brilliant  red  cytoplasm  distinguish  them  sharply  from  other 
cells. 


CHRONIC  INFLAMMATION  19 

of  an  irritant  to  some  superficial  part  of  the  body,  usually  the  skin, 
either  over  the  seat  of  the  inflammation  or  at  a  little  distance  from  it ; 
the  application  should  be  made  to  a  part  which  is  in  intimate  nervous 
connection  with  the  inflamed  area.  It  is  not  clear  how  benefit  results 
from  irritation  of  the  skin  ;  probably  the  irritant  acts  through  the 
nervous  system.  Poultices  and  fomentations,  which  are  of  such  value  in 
acute  inflammation,  probable  owe  their  virtue  partly  to  the  principle 
of  counter-irritation,  and  they  may  be  classed  as  the  mildest  counter- 
irritants  with  which  we  are  acquainted.  In  chronic  inflammation, 
however,  some  more  active  agent  is  usually  necessary. 

Mustard  is  one  of  the  mildest  counter-irritants  in  common  use,  and 
is  employed  either  in  the  form  of  mustard-leaves  or  as  a  plaster.  The 
mustard-leaves,  which  only  require  damping  before  being  applied,  are 
very  handy  and  cleanly,  and  are  generally  used  when  counter-irritation 
alone  is  required.  As  a  substitute  for  them,  the  ordinary  mustard-plaster, 
made  by  mixing  mustard  into  a  thick  paste  with  tepid  water  and 
spreading  it  on  a  piece  of  linen  or  brown  paper,  may  be  employed. 
The  length  of  time  that  either  of  these  preparations  should  be  left  on 
is  determined  by  the  patient's  sensations.  Ten  to  twenty  minutes  is 
generally  sufficient ;  if  left  on  longer  they  are  apt  to  blister.  Special 
care  should  be  taken  not  to  leave  them  too  long  on  young  children, 
in  whom  they  may  produce  actual  sloughing. 

If  the  warm  poultice  action  be  required  in  addition  to  the  counter- 
irritation,  a  mustard-and-linseed  poultice  may  be  employed.  The  poultice 
is  made  with  boiling  water  in  the  ordinary  way  (see  p.  n),  one  part  of 
mustard  being  added  to  four  parts  of  linseed  meal.  If  a  more  energetic 
action  be  required,  an  ordinary  linseed  poultice  is  made,  and  mustard  is 
dusted  thickly  over  its  surface. 

The  most  popular  method  of  producing  counter-irritation  is  by  the 
use  of  tincture  of  iodine  or  of  linimentum  iodi,  the  part  being  painted  with 
the  iodine  every  day  until  the  skin  becomes  so  sore  that  the  patient 
cannot  go  on  with  it.  As  a  rule,  however,  the  effects  of  iodine  are  not 
satisfactory,  and  in  many  cases  of  tuberculous  glands,  in  which  it  is 
so  commonly  used,  it  is  positively  harmful,  as  it  tends  to  bring  about 
suppuration.  The  two  most  potent  agents  in  producing  smart 
counter-irritation  are  blisters  and  the  actual  cautery. 

Blisters  may  be  produced  either  by  the  emplastrum  cantharidis  (B.P.) 
or  by  the  liquor  epispasticus.  The  part  to  which  a  blister  is  to  be  applied 
should  be  thoroughly  cleansed,  and  if  necessary,  shaved.  In  an  adult 
the  plaster  should  be  left  on  for  about  ten  hours ;  the  length  of  time 
required  for  the  production  of  a  satisfactory  effect  varies,  however,  with 
the  thickness  of  the  skin.  In  children,  and  in  parts  where  the  skin  is  thin, 
about  five  or  six  hours  will  generally  be  sufficient ;  on  the  other  hand, 
where  the  skin  is  thick,  as  on  the  palm  or  the  sole,  it  may  even  require 
twenty-four  hours.  When  the  plaster  is  removed,  a  good-sized  blister 


20  INFLAMMATION  AND  ITS  SEQUELAE 

is  generally  found  beneath  it ;  sometimes,  however,  the  skin  is  merely 
reddened,  or  a  few  small  vesicles  only  are  present.  In  these  cases  the 
subsequent  application  of  a  fomentation  or  a  poultice  will  facilitate  the 
formation  of  the  blister.  If  a  drop  or  two  of  croton  oil  be  rubbed  over 
the  surface  of  the  plaster  before  application,  its  effect  will  be  considerably 
enhanced.  If,  however,  the  blister  does  not  rise  properly  in  the  course 
of  a  few  hours,  painting  the  skin  with  the  liquor  epispasticus  and  allow- 
ing it  to  dry  will  usually  produce  a  satisfactory  result.  Some  prefer  the 
liquor  epispasticus  alone,  painting  it  over  the  part  two  or  three  times 
in  succession  and  allowing  it  to  dry  between  each  application.  It  must 
be  freshly  prepared,  as  otherwise  it  is  very  uncertain  in  its  action. 

Emp.  cantharidis  must  not  be  left  on  too  long  for  fear  of  causing 
sloughing  of  the  skin,  and  the  danger  that  the  patient  runs  of  absorbing 
the  drug  must  be  borne  in  mind ;  should  this  happen,  there  is  considerable 
risk  of  nephritis.  Blisters  should  not  be  applied,  therefore,  over  large 
areas  covered  by  thin  skin,  and  should  not  be  used  at  all  when  there 
is  any  renal  disease.  When  the  inflammation  is  still  active  and  is 
affecting  the  skin  or  the  subcutaneous  tissues,  the  blister  should  not  be 
applied  immediately  over  the  seat  of  disease,  lest  it  should  increase  the 
congestion  of  the  part,  and  thus  augment  the  inflammation  ;  it  is  better 
to  apply  it  some  little  distance  away.  When  the  inflammation  is  sub- 
siding, however,  there  is  not  the  same  objection  to  applying  it  directly 
over  the  affected  area ;  on  the  contrary,  the  increased  flow  of  blood 
and  lymph  which  is  thus  set  up  may  be  very  beneficial.  When  the 
inflammation  is  deeply  seated,  the  best  effect  is  usually  got  by  applying 
the  blister  directly  over  the  spot. 

The  actual  cautery  is  a  most  potent  means  of  producing  counter- 
irritation,  and  is  used  either  to  form  one  large  sore  or  a  number  of  small 
ones ;  the  former  is  probably  the  more  effectual  method.  In  spinal 
disease,  for  example,  the  production  of  a  superficial  sore  three  inches  in 
length  and  two  in  breadth,  on  each  side  of  the  spine,  will  often  do  much 
good.  Similarly,  in  hip-joint  disease,  two  sores,  one  in  front  and  one 
behind  the  joint,  will  often  relieve  the  acute  starting  pains  from  which 
the  patient  surfers.  Only  the  superficial  part  of  the  skin  should  be 
acted  on,  as  it  is  important  that  the  whole  thickness  should  not  be 
destroyed.  In  order  to  produce  these  large  sores  effectually,  and  with- 
out too  much  destruction  of  tissue,  it  is  best  to  use  a  flat,  iron  cautery  under 
anaesthesia  (see  Fig.  7).  The  cautery  must  be  at  a  bright  red  heat,  for 
otherwise  it  is  difficult  to  gauge  the  amount  of  destruction  of  the  skin 
produced.  When  a  cautery  is  thus  used,  it  suffices  to  rub  it  quickly  two 
or  three  times  over  the  part  in  order  to  produce  the  desired  amount 
of  burning.  It  is  only  necessary  to  destroy  the  epidermis  and  portions 
of  the  rete  mucosum,  and  thus  lay  bare  a  large  number  of  the 
nerve-endings.  After  the  cautery  has  been  applied,  poultices  or  hot 
fomentations  should  be  used  until  the  slough  separates,  which  will  occur 


CHRONIC  INFLAMMATION  21 

in  four  or  five  days.  If  now  the  wound  were  left  to  itself,  or  merely 
dressed  with  some  simple  ointment,  it  would  heal  with  great  rapidity, 
because  the  skin  has  not  been  deeply  destroyed,  and  there  are  numerous 
points  from  which  epithelium  would  quickly  spread  over  the  part.  In 
order  to  get  the  best  effect  from  the  actual  cautery,  it  is  necessary 
to  keep  the  sore  open  for  a  few  weeks,  and  this  can  only  be  done  by  the 
application  of  some  irritant  to  the  sore  after  the  slough  has  separated. 
Savin  ointment  is  usually  employed  for  this  purpose,  but  many  patients 
are  unable  to  bear  the  pain  caused  by  the  pure  ointment  for  any 
length  of  time,  and  in  most  cases  it  is  necessary  to  dilute  it  with  an  equal 
part  of  simple  ointment,  to  add  about  5  to  10  per  cent,  of  cocaine,  eucaine, 
or  novocaine,  or  to  sprinkle  the  part  with  orthoform.  Even  when  savin 
ointment  is  used,  healing  is  often  too  rapid,  and  it  may  be  necessary  to 
destroy  the  young  epithelium  on  the  surface  of  the  sore  from  time  to 
time  with  nitrate  of  silver,  or,  if  that  does  not  suffice,  to  apply  potassa 
fusa.i  It  is  remarkable  how  quickly  the  pain,  even  when  severe,  disap- 
pears after  the  application  of  the  cautery,  and  how  it  will  often  recur 
if  the  wound  be  allowed  to  heal  too  rapidly. 


FIG.  7. — FLAT  CAUTERY.    The  flat  surface  is  generally  used,  but  the  edge  can  be 
employed  if  it  be  desired  to  score  lines  upon  the  skin. 

Another  form  of  cautery  is  that  known  as  Corrigan's  cautery,  or  the 
button  cautery.  This  is  a  small,  round,  metal  button  fixed  in  a  handle.  It 
is  heated  to  a  red  heat  and  pressed  for  a  moment  on  the  part ;  by  it  a 
number  of  little  sores  can  be  produced.  The  effect  of  this  small  cautery, 
however,  is  not  so  good  as  that  of  the  larger  one,  at  any  rate  in  extensive 
inflammation  of  bone.  When  this  cautery  is  not  at  hand,  a  similar  effect 
can  be  produced  by  the  broad  blade  of  a  Paquelin's  cautery. 

The  Paqnelin  cautery  is  very  useful  when  a  milder  effect  is  required. 
The  broad  platinum  point  is  heated  to  a  bright  red  or  a  white  heat  and 
then  lightly  and  rapidly  drawn  across  the  skin  so  as  to  produce  a  series 
of  parallel  lines.  Another  set  is  then  made  crossing  these  at  an  angle 
so  that  there  is  a  sort  of  '  cross  hatching '  over  the  desired  area.  If  the 
cautery  be  white-hot,  and  applied  rapidly  enough  with  a  sort  of  flicking 
motion,  this  operation  is  practically  painless  and  no  anaesthetic  is  required. 
The  after  effect  is  to  produce  a  sensation  similar  to  that  of  a  mustard 
plaster.  There  is  no  need  to  apply  any  dressing  if  the  cautery  be  applied 
in  this  way,  as  there  is  no  injury  to  the  deeper  parts  of  the  skin,  the  cuticle 
alone  being  charred. 

Free    incision  into  the  part,   removing  if  possible  a    piece  for 

1  A  stick  of  potassa  fusa  is  held  in  a  pair  of  forceps  and  rubbed  quickly  over 
the  part,  which  is  then  covered  with  lint  steeped  in  vinegar. 


22 


INFLAMMATION  AND  ITS  SEQUELS 


microscopical  examination,  is  of  the  utmost  value  in  many  cases  of  chronic 
inflammation.  For  example,  in  chronic  periostitis  there  is  nothing  that 
relieves  the  pain  and  improves  the  condition  so  much  as  a  free  aseptic 
incision ;  the  effect  of  this  is  much  increased  if  the  thickened  periosteum 
be  taken  away  at  the  same  tune.  Similarly,  in  chronic  osteitis  the  best 
method  of  treatment  is  to  gouge  away  a  large  portion  of  the  inflamed 
bone.  Even  although  the  whole  of  the  affected  area  be  not  removed,  the 
rest  very  soon  improves,  and  the  patient  is  much  relieved,  and  often  cured. 
It  must  not  be  forgotten  that  free  incision  plays  a  dual  role  in  many 
doubtful  cases  simulating  chronic  inflammation ;  it  may  be  curative,  but 
in  any  case  it  is  of  great  value  in  diagnosis.  Knowing  that  free  incision 
into  a  chronically  inflamed  part  is  one  of  the  best  means  of  treating  the 


FIG.  8. — GAS  STOVE   FOR  HEATING   CAUTERIES.    This  is  an  ordinary  soldering  stove  which 
will  raise  the  cauteries  to  the  desired  temperature  in  a  very  short  time. 

inflammation,  there  need  be  no  hesitation  in  ascertaining  the  true  state 
of  matters  by  making  a  free  incision.  Should  it  turn  out  that  there  is 
a  tumour,  the  diagnosis  is  made,  and  the  surgeon  can  treat  the  case  as 
is  required.  On  the  other  hand,  should  the  case  prove  to  be  one  of 
chronic  inflammation,  the  most  effectual  steps  have  been  taken  to  cure 
the  patient. 

Pressure  in  cases  of  chronic  inflammation,  is  mainly  of  value  when 
the  process  is  subsiding ;  if  it  be  applied  when  the  inflammation  is 
active,  it  is  apt  to  increase  the  latter  instead  of  diminishing  it.  When, 
however,  the  inflammation  is  subsiding,  pressure  is  most  valuable ;  in 
cases  of  thickening  of  the  epididymis  after  acute  epididymitis,  for  example, 
strapping  the  testicle  is  the  favourite  and  best  method  of  treatment. 
Pressure  is  also  frequently  employed  for  chronic  inflammation  of  joints, 
whether  due  to  tuberculosis  or  not.  The  essential  point  in  employing 
pressure  is  that  it  should  be  equable  and  not  too  great ;  an  excellent  way 


CHRONIC  INFLAMMATION  23 

to  obtain  it  is  to  surround  the  part  with  a  large  mass  of  cotton-wool  or 
silk  waste  in  even  sheets  or  layers,  and  then  to  apply  a  bandage  over  this 
as  tightly  as  possible.  Some  starch  or  silicate  of  soda  solution  should 
be  rubbed  into  the  bandage  to  prevent  it  from  becoming  loose.  This 
method  is  particularly  applicable  to  cases  of  joint  disease.  An  elastic 
bandage  may  be  applied  lightly  outside  the  wool.  Pressure  may  be 
also  applied  by  means  of  Scott's  dressing,  which  combines  pressure  with 
counter-irritation,  and  is  most  useful  in  joint  diseases.  Compound 
mercury  ointment  (unguentum  hydrargyri  co.)  is  spread  upon  chamois 
leather  which  is  cut  into  strips  and  applied  firmly,  like  other  forms  of 
strapping,  in  imbricated  layers  around  the  diseased  part.  Outside  this 
a  layer  of  cotton-wool  is  applied  and  bandaged  on  firmly ;  the  limb  is 
then  placed  upon  a  splint.  Scott's  dressing  may  be  applied  more  eco- 
nomically by  spreading  the  ointment  upon  a  large  piece  of  lint,  which  is 
then  cut  into  strips,  and  these  are  applied  to  the  limb  in  the  usual 
imbricated  layers.  Outside  these,  ordinary  strapping  is  applied  in  a  similar 
manner  ;  a  splint  is  not  always  necessary.  The  part  should  be  shaved 
before  the  strapping  is  applied,  and  the  dressing  should  be  renewed 
every  four  or  five  days,  both  because  the  skin  is  apt  to  become  raw,  and 
also  because  the  strapping  slips  and  the  dressing  becomes  loose. 

Massage  is  chiefly  of  value  when  the  chronic  inflammatory  process 
has  come  nearly  to  a  standstill,  and  it  is  a  question  of  causing  absorption 
of  the  inflammatory  products.  Massage  employed  during  the  active 
stage  is  apt  to  make  matters  worse.  The  essential  principles  of  massage 
are  first  to  break  up  the  products  of  the  chronic  inflammation,  and  then 
to  promote  the  absorption  of  the  broken-up  materials  by  the  lymphatic 
vessels.  There  are  various  ways  of  breaking  up  the  new  material ;  the 
mildest  form  is  termed  '  friction  massage,'  and  in  it  the  part  is  rubbed 
in  a  circular  manner  with  two  or  three  fingers  of  one  hand  for  some  time, 
and  then  the  material  is  forced  into  the  lymphatic  vessels  by  an  upward 
uniform  pressure,  called  '  effleurage.'  In  effleurage,  the  part  which  has 
been  subjected  to  the  friction  is  grasped  with  the  whole  hand,  and  is 
firmly  and  gently  squeezed  in  an  upward  direction.  This  is  repeated  a 
number  of  times,  when  the  friction  is  resumed,  and  again  the  effleurage 
follows.  When  the  material  is  more  difficult  to  break  up,  another  action, 
called  '  petrissage  '  or  firm  kneading  of  the  part,  is  resorted  to.  The 
part  is  grasped  between  the  fingers  and  the  thumb,  and  is  firmly 
kneaded  ;  after  the  kneading,  the  broken-up  products  are  forced  into  the 
lymphatics  by  effleurage.  When  the  material  is  still  more  dense,  and 
especially  when  it  is  limited  to  a  small  area,  the  action  of  '  tapotement ' 
is  employed  ;  in  this  the  part  is  firmly  tapped,  either  with  the  fingers  or 
a  special  instrument,  and,  after  repeated  and  violent  tappings  as  hard 
as  the  patient  can  bear,  effleurage  is  again  carried  out.  At  first,  massage 
should  be  very  gentle,  but  the  more  forcible  measures  may  be  adopted 
as  the  patient  becomes  accustomed  to  it.  As  a  rule,  a  daily  sitting  of 


24  INFLAMMATION  AND  ITS  SEQUELS 

twenty  minutes  is  sufficient ;  but  there  may  be  two  sittings  daily, 
morning  and  evening,  after  three  or  four  days,  if  distinct  benefit  results, 
and  the  length  of  the  sittings  may  be  increased  to  three-quarters  of  an 
hour  or  an  hour  as  time  goes  on.  The  length  of  time  required  for  a  cure 
depends  entirely  on  the  nature  of  the  case  and  the  progress  made  ;  except 
in  extensive  and  obstinate  cases,  three  weeks  generally  suffice.  Massage 
is  especially  useful  after  inflammations  which  cause  adhesion  either 
between  muscles,  or  between  tendons  and  their  sheaths,  or  in  joints  or 
in  any  situation  in  which  much  thickening  is  left  after  inflammation  or 
injury. 

An  efficient  substitute  for  ordinary  massage  can  be  found  in  what  might 
be  called  automatic  massage.  For  example,  in  a  sprain  of  the  ankle  it  is 
often  a  good  practice  to  strap  the  joint  firmly.  If  the  strapping  be 
confined  to  the  immediate  neighbourhood  of  the  joint,  it  will  be  pro- 
ductive of  nothing  but  discomfort ;  the  limb  will  swell  around  the  strap- 
ping, which  will  cut  into  the  leg,  and  may  give  rise  to  unpleasant  sores. 
If,  however,  the  strapping  be  carried  well  beyond  the  joint  on  both  sides 
— in  the  ankle,  for  example — from  the  base  of  the  toes  to  the  knee,  so  as  to 
encase  the  whole  of  the  leg  and  foot  in  a  comparatively  rigid  shell,  every 
movement  of  the  muscles  will  squeeze  the  lymph  and  venous  blood  from 
their  interstices,  and  the  extension  of  the  strapping  up  the  leg  will  carry 
the  effusion  into  the  region  where  the  vascular  and  lymphatic  arrange- 
ments are  normal.  The  strapping  should  be  carefully  applied  in  narrow 
strips  about  an  inch  wide,  overlapping  about  one-third  of  their  width, 
and  the  limb  should  be  shaved  before  strapping.  With  a  strapping  applied 
in  this  way,  there  is  no  necessity  to  confine  the  patient  to  bed  or  the  couch  ; 
indeed,  it  is  only  by  using  the  limb  that  the  strapping  can  exert  its  proper 
effect,  for  the  massaging  action  can  only  take  place  when  the  muscles 
within  the  casing  are  moving  and  altering  in  shape.  The  patient,  there- 
fore, should  be  allowed  to  use  the  limb  freely.  Over-use  is  harmful,  but 
the  presence  of  the  strapping  is  in  itself  usually  sufficient  to  restrain  the 
patient  from  this  indiscretion. 

General  Treatment. — In  chronic  inflammation  the  constitutional 
treatment  depends  rather  on  the  disease  which  is  the  cause  of  the  process 
than  on  the  process  itself.  It  is  essential  that  the  patient  should  be 
under  the  best  possible  hygienic  conditions,  and  that  he  should  have 
plenty  of  nourishing  food ;  when  the  patient  is  weakly,  stimulants  will 
be  necessary.  If  required,  the  usual  remedies  for  gout,  rheumatism, 
syphilis,  etc.,  must  be  employed.  Iodide  of  potassium  and  mercury 
in  small  doses  are  administered  in  some  cases  of  chronic  inflammation 
not  due  to  syphilis,  but,  as  a  rule,  they  do  not  then  produce  any  marked 
effect. 


CHAPTER   II. 
ACUTE  SUPPURATION. 

DEFINITION". — By  acute  suppuration  is  meant  a  process  in  which 
the  inflammation,  after  reaching  the  stage  of  granulation,  goes  on  to 
liquefaction  of  the  tissues  and  the  formation  of  pus.  Pus  is  a  fluid  con- 
taining in  suspension  cells,  chiefly  leucocytes,  and  it  may  either  form  in  the 
substance  of  the  tissues,  when  the  inflammation  is  deep-seated,  or  be  given 
off  from  a  free  surface.  We  shall  only  consider  here  the  question  of 
suppuration  as  it  occurs  in  the  substance  of  the  tissues  ;  suppuration  from 
a  free  surface  will  be  discussed  in  connection  with  the  treatment  of 
\vounds  and  ulcers. 

Suppuration  in  the  tissues  occurs  under  two  forms.  In  the  one,  the 
pus  is  contained  in  a  well-defined  cavity  with  a  distinct  wall  formed  of 
granulation  tissue ;  in  the  other,  it  infiltrates  the  cellular  tissue  and  there 
is  no  proper  limiting  membrane,  the  tissues  being,  so  to  speak,  soaked 
with  the  purulent  material.  The  former  is  the  ordinary  circumscribed 
acute  abscess,  the  latter  is  the  much  more  dangerous  form  of  suppuration 
known  as  diffuse  cellulitis. 

CAUSES. — Acute  suppuration  is  always  due  to  pyogenic  organisms, 
the  circumscribed  abscess  being  most  frequently  caused  by  the  staphylo- 
coccus  pyogenes  aureus  or  albus  and  by  other  less  virulent  forms,  especially 
the  pneumococcus  ;  diffuse  cellulitis  is  usually  caused  by  the  streptococcus 
pyogenes.  Although  these  organisms  are  the  essential  cause  of  acute 
suppuration,  they  will  not  necessarily  cause  suppuration  unless  they 
are  present  in  large  numbers  or  in  a  state  of  extreme  virulence.  In 
most  cases  other  accessory  factors  are  present  which  favour  the  growth 
of  the  organisms,  as,  for  example,  conditions  enabling  the  organisms  to 
rest  in  the  part,  or  producing  a  weak  spot  where  the  tissues  are  less 
resistent  than  elsewhere.  Thus,  it  is  not  uncommon  to  find  acute  abscesses 
forming  in  parts  that  have  been  injured,  or  have  been  the  seat  of  in- 
flammation, since  the  tissues  there  are  in  a  weak  state  and  not  well 
calculated  to  resist  the  attack  of  the  parasite.  The  organisms  reach  the 

25 


26  INFLAMMATION  AND  ITS  SEQUELS 

part  either  directly  through  a  wound,  or  indirectly  through  the  lymphatic 
vessels  or  the  blood-stream.  In  the  case  of  an  acute  abscess  the  entrance 
is  usually  more  or  less  direct.  The  organisms  may  either  gain  entrance 
to  the  blood  through  wounds,  or  they  may  pass  through  an  unbroken 
surface  which  is  no  longer  quite  healthy  ;  this  is  most  prone  to  occur  in 
the  intestinal  mucous  membrane,  and  in  acute  suppurative  periostitis 
or  osteomyelitis  it  is  not  uncommon  to  obtain  a  history  of  diarrhoea  or 
some  other  intestinal  derangement  immediately  preceding  the  onset  of  the 
attack.  The  time  taken  for  the  formation  of  an  acute  abscess  varies, 
and  in  some  cases  a  considerable  interval  elapses  between  the  onset  of 
the  inflammation  and  the  definite  formation  of  pus.  These  cases,  how- 
ever, should  really  be  classed  as  '  sub-acute  abscesses.' 

Mode  of  Extension. — When  an  acute  abscess  has  formed,  its 
tendency  is  to  make  its  way  to  the  free  surface  of  the  skin  or  mucous 
membrane,  the  extension  not  being  a  mechanical  process  due  to  the 
pressure  of  the  pus,  but  an  active  and  vital  one.  This  is  what  is  known 
as  the  '  burrowing '  of  the  abscess.  When  an  abscess  forms  beneath 
the  skin,  it  spreads  to  this  structure,  and  ultimately  bursts  through 
it  in  preference  to  burrowing  along  the  subcutaneous  cellular  tissue, 
because  the  vital  changes  in  skin  are  more  active  than  in  the  deeper 
tissues,  and  granulation  tissue  is  formed  there  more  quickly.  When 
an  abscess  forms  beneath  a  dense  fascia,  the  conditions  are  different. 
The  fascia  is  not  converted  into  granulation  tissue  so  quickly  as  is  the 
areolar  tissue  beneath,  and,  consequently,  an  abscess  so  confined  will, 
if  left  unopened,  extend  for  long  distances  and  in  various  directions 
beneath  the  fascia.  Ultimately,  however,  the  fascia  undergoes  granu- 
lation, or  sloughs  owing  to  the  interference  with  its  blood-supply  by  the 
pressure  of  the  pus,  and  the  latter  escapes  into  the  subcutaneous  tissue. 
As  soon  as  this  takes  place,  the  abscess  behaves  like  a  subcutaneous 
one  and  perforates  the  skin.  The  mode  in  which  the  abscess  burrows 
is  of  great  importance  from  the  point  of  view  of  treatment.  If  an  acute 
abscess  be  left  unopened  until  a  late  period,  it  will  be  found  to  be  no  longer 
a  single  round  cavity,  but  to  contain  numerous  diverticula  corresponding 
to  the  directions  in  which  the  inflammation  has  extended  in  the  deeper 
tissues.  Unless  these  diverticula  be  opened  up  thoroughly,  mere  evacua- 
tion of  the  superficial  portion  of  the  abscess  often  fails  to  arrest  the 
suppuration.  Perhaps  the  best  example  of  this  is  seen  in  the  breast,  where 
the  abscess  rarely  consists  of  a  single  round  cavity,  but  usually  possesses 
many  diverticula,  corresponding  to  the  blood-vessels  and  lymphatics 
which  accompany  the  ducts  and  lobules  of  the  breast.  Unless  an  abscess 
of  this  kind  be  opened  in  the  manner  described  below,  the  pus  in  these 
diverticula  will  not  be  evacuated  properly,  and  may  lead  to  fresh  exten- 
sions, the  ultimate  result  being  that  the  entire  breast  becomes  riddled 
with  sinuses. 


CIRCUMSCRIBED   ACUTE   ABSCESS  27 


CIRCUMSCRIBED   ACUTE   ABSCESS. 

SYMPTOMS. — When  an  acute  inflammation  which  has  gone  on  to 
the  formation  of  granulation  tissue  has  lasted  for  four  or  five  days, 
suppuration  will  almost  certainly  occur,  and  when  this  takes  place,  the 
centre  of  the  brawny  swelling  softens,  and  fluctuation  can  be  detected. 
When  the  abscess  is  subcutaneous,  the  skin  ultimately  gives  way  over  the 
soft  spot,  and  pus  escapes.  When  the  abscess  is  deep-seated,  the  presence 
of  pus  may  not  be  recognised  at  an  early  period,  but  persistence  of  the 
acute  symptoms  for  several  days  and  oedema  of  the  skin  over  the  part 
are  generally  sufficient  indications;  more  precise  information  may  be 
obtained  by  a  blood-count  (see  Appendix). 

TREATMENT. — Local. — When  pus  has  formed,  it  should  be 
evacuated  as  soon  as  possible.  If  the  abscess  remain  unopened,  it  will 
spread  and  cause  unnecessary  destruction  of  tissue,  besides  in  some  cases 
imperilling  the  patient's  life.  Hence,  when  symptoms  of  acute  inflam- 
mation have  lasted  for  several  days,  and  especially  if  there  be  oedema  of 
the  skin  over  the  part,  and  still  more  if  rigors  have  occurred,  no  time 
should  be  lost  in  making  an  incision  to  evacuate  the  pus. 

Opening  an  Abscess. — All  the  antiseptic  precautions  should  be 
adopted  that  are  practised  in  the  treatment  of  wounds  (see  Chap.  V.). 
This  may  seem  an  unnecessary  precaution,  because  these  abscesses,  being 
due  to  pyogenic  cocci,  already  contain  the  causes  of  suppuration.  In 
practice,  however,  it  is  found  most  important  to  treat  the  abscess  strictly 
antiseptically  from  the  first.  As  a  matter  of  fact,  when  an  abscess  is 
opened  antiseptically  it  is  comparatively  easy  to  keep  it  aseptic,  and  no 
further  suppuration  occurs.  On  removing  the  first  dressings,  a  small 
quantity  of  pus  will  no  doubt  be  seen,  but  this  is  only  the  residual  pus 
present  in  the  abscess  when  it  was  opened,  and  if  the  cavity  be  squeezed, 
all  that  is  expelled  is  a  small  quantity  of  clear  serum ;  this  rapidly 
diminishes,  and  in  a  few  days  the  abscess  cavity  closes.  On  the  other 
hand,  when  the  abscess  is  not  treated  antiseptically  from  the  first,  sup- 
puration persists.  If,  for  example,  a  poultice  be  applied,  it  will  be  found 
that  pus  can  be  squeezed  out,  or  will  even  flow  out  spontaneously  when- 
ever the  poultice  is  removed ;  this  is  evidently  due  to  fresh  infection  of 
the  cavity,  for,  when  asepsis  is  maintained,  the  organisms  which  originally 
caused  the  abscess  die  out. 

It  is  of  great  importance  to  prevent  infection  of  the  surgeon's  hands, 
so  as  to  avoid  carrying  pyogenic  cocci  to  another  case.  Hence,  rubber 
gloves  should  always  be  worn,  and  they  must  be  kept  on  not  only  during 
the  actual  operation,  but  until  the  dressing  has  been  applied  and  all 
blood  and  pus  cleared  away.  Unless  this  be  done,  the  surgeon's  hands 
may  become  infected  with  pus  from  a  soiled  towel  or  some  other  article. 

The  incision  into   an  acute  abscess  should  be  made  at  the  most 


28  INFLAMMATION  AND  ITS  SEQUELS 

dependent  spot,  if  this  be  possible,  and,  when  the  appearance  of  the  sub- 
sequent scar  is  of  importance,  in  the  lines  of  cleavage  of  the  skin.  Thus, 
abscesses  in  the  neck  should  be  opened  by  oblique  rather  than  by  longi- 
tudinal incisions  (see  Fig.  34).  When  the  size  of  the  scar  is  not  a  matter 
of  importance,  the  skin  incision  should  be  long  enough  to  allow  the 
surgeon  to  introduce  his  finger  and  explore  all  the  recesses  of  the  abscess 
cavity  and  break  down  any  septa  that  may  be  present ;  as  a  rule  this 
cannot  be  done  satisfactorily  without  the  aid  of  touch.  When  the  abscess 
is  superficial  and  the  size  of  the  scar  a  matter  of  importance,  it  is  allow- 
able to  make  an  incision  only  just  large  enough  to  admit  a  pair  of  dress- 
ing forceps.  The  forceps  are  introduced  into  the  interior  of  the  abscess 
cavity  and  pushed  in  all  directions  and  the  blades  frequently  expanded, 
so  that  any  septa  present  may  be  broken  down  and  the  cavity  thoroughly 
opened  ;  a  small  drainage  tube  is  then  inserted.  In  situations,  such  as 
the  anterior  triangle  of  the  neck,  where  the  use  of  the  knife  in  the  deeper 
tissues  would  endanger  important  structures,  some  surgeons  prefer  to 
open  the  abscess  by  what  is  known  as  Hilton's  method.  In  this  plan 
the  knife  is  laid  aside  as  soon  as  the  skin  has  been  incised,  and  the  deeper 
tissues  are  carefully  bored  through  with  a  pair  of  fine  dressing  or  sinus 
forceps  until  the  pus  is  reached.  When  the  forceps  have  entered  the  abscess 
cavity,  the  blades  are  expanded  until  a  sufficient  opening  has  been  torn 
in  the  tissues  to  enable  a  drainage  tube  to  be  introduced.  Before  they 
are  removed,  the  forceps  should  be  pushed  into  the  abscess  cavity  in  all 
directions  and  the  blades  frequently  expanded  so  as  to  break  down  any 
septa  present.  When  an  abscess  has  been  opened  in  this  way,  a  probe 
should  be  passed  along  the  forceps  before  they  are  withdrawn,  so  as  to 
act  as  a  guide  for  the  introduction  of  the  drainage  tube.  Unless  this  be 
done,  the  opening  in  the  fascia  through  which  the  forceps  entered  may 
be  missed,  for  it  is  not  always  in  a  direct  line  with  the  opening  in  the 
skin.  The  simplest  way  of  introducing  the  drainage  tube  is  to  thread 
it  over  the  probe ;  the  lower  end  of  the  tube  is  grasped  with  the  sinus 
forceps  and  pushed  into  the  abscess  cavity,  and  the  probe  is  then  with- 
dfawn  whilst  the  forceps  hold  the  tube  in  position. 

Drainage. — After  the  abscess  cavity  has  been  opened  freely,  and  all 
diverticula  present  have  been  opened  up,  the  pus  should  be  squeezed 
out  gently,  violence  being  avoided  lest  the  granulation  tissue  should  be 
injured.  An  indiarubber  drainage  tube,  which  should  always  be  as 
large  as  can  be  introduced  conveniently,  should  then  be  inserted  so  that 
its  end  projects  into  the  abscess  cavity ;  this  end  of  the  tube  should 
be  perforated  with  a  number  of  large  openings  through  which  the  dis- 
charge can  escape.  When  the  abscess  cavity  is  very  small,  and  does 
not  extend  to  any  depth,  it  may  not  be  possible  to  introduce  a  drainage 
tube  of  sufficient  size  to  be  of  use  ;  and  in  that  case  a  narrow  strip  of 
gauze,  dipped  in  a  i  in  2000  sublimate  solution,  may  be  laid  between  the 
lips  of  the  incision  throughout  its  entire  length  ;  this  suffices  to  keep  the 


CIRCUMSCRIBED   ACUTE  ABSCESS  29 

wound  open  sufficiently  for  drainage,  and  may  be  discontinued  in  a  few 
days. 

When  the  abscess  is  very  large,  and  particularly  when  the  pus  has 
burrowed  for  a  considerable  distance,  it  is  often  necessary  to  provide 
a  second,  or  counter-opening,  to  ensure  efficient  drainage ;  this  is  more 
especially  necessary  when  the  original  opening  has  not  been  made  at  the 
most  dependent  point  of  the  abscess  cavity.  In  order  to  make  a  counter- 
opening,  a  pair  of  long  dressing  forceps  are  inserted  into  the  cavity  with 
the  blades  closed,  passed  down  to  the  most  dependent  point,  and  then 
thrust  forcibly  through  the  soft  parts  so  that  they  project  beneath  the 
skin.  An  incision  is  then  made  through  the  skin  to  expose  the  points, 
and  the  blades  are  separated  and  made  to  grasp  a  drainage  tube,  which 
is  pulled  through  the  aperture.  The  outer  end  of  the  tube  should  be 
cut  off  flush  with  the  skin,  and  stitched  to  it.  This  is  the  simplest  plan 
for  securing  a  drainage  tube,  and  the  most  certain  to  keep  it  in  its  place 
if  the  patient  is  under  an  anaesthetic  ;  if  not,  it  suffices  to  transfix 
the  end  of  the  drainage  tube  with  a  sterilised  safety-pin.  When  the 
tube  is  to  be  stitched  to  the  skin  it  is  well  not  to  push  it  quite  down 
to  the  bottom  of  the  cavity  because  the  swelling  subsides  rapidly,  and 
in  twenty-four  hours  a  tube  which  at  first  hardly  reached  the  bottom 
of  the  cavity  may  be  pushed  up  considerably,  pulling  the  skin  with  it. 
It  is  sufficient  if  the  tube  enters  the  abscess  cavity  or  any  recess  that 
requires  drainage.  Gauze  wicks,  which  are  often  recommended,  are 
not  nearly  so  efficient  as  drainage  tubes  in  the  case  of  abscesses,  and,  if 
continued  for  any  length  of  time,  prevent  the  healing  of  the  wound. 

The  practice,  so  common  nowadays,  of  tightly  packing  the  opening 
into  an  acute  abscess  should  be  carefully  avoided.  It  is  by  no  means 
uncommon  for  a  strip  of  gauze  to  be  packed  tightly  into  the  opening  of  an 
abscess  cavity,  the  surgeon  being  under  the  impression  that  it  is  acting  as 
a  capillary  drain.  Removal  of  this  strip  of  gauze  is  followed  by  a  gush  of 
pus  which  has  been  dammed  up  behind  it ;  and  it  is  evident  that  such 
a  method  of  treatment  has  not  only  not  assisted  recovery  but  has  actually 
retarded  it ;  in  such  cases  the  insertion  of  a  drainage  tube  is  usually 
followed  rapidly  by  beneficial  results.  When  the  abscess  cavity  has 
contracted  down  to  a  sinus,  healing  is  often  delayed  by  the  assiduous  care 
with  which  a  long  strip  of  gauze  is  thrust  down  to  its  bottom ;  this  acts 
as  a  seton,  keeping  up  inflammation  and  suppuration,  and  its  mere  removal 
will  often  be  followed  by  rapid  healing  of  the  sinus. 

The  plan  of  washing  out  acute  abscesses  after  they  have  been  opened 
is  not  to  be  recommended ;  it  can  do  no  good  whatever  in  the  way  of 
disinfecting  the  abscess,  whilst  it  is  very  apt  to  injure  the  granulation 
wall,  and  thus  produce  a  weak  spot  in  which  the  organisms,  which  would 
otherwise  die  out,  can  spread.  Similarly,  any  curetting  of  the  cavity 
is  to  be  strongly  deprecated.  When,  however,  the  discharge  is  very 
foul,  irrigation  (as  recommended  below)  may  be  very  useful. 


30  INFLAMMATION  AND  ITS  SEQUELS 

! 

After-treatment. — In  considering  the  after-treatment,  it  may  be 
pointed  out  that  in  practice  we  have  to  deal  with  two  types  of  acute 
abscess : — 

i.  Abscesses  of  which  the  type  is  the  ordinary  subcutaneous 
abscess  due  to  the  various  forms  of  staphylococci,  in  which  there 
are  no  sloughs  and  in  which  good  drainage  can  be  obtained. 

ii.  Abscesses  in  which  portions  of  dead  tissue  (sloughs,  necrosed 
bone,  etc.)  are  present,  those  due  to  other  than  the  ordinary  pyo- 
genic  organisms,  or  those  in  which  drainage  is  imperfect,  e.g., 
appendicitic  abscesses. 

The  subsequent  progress  of  these  cases,  and  to  some  extent  their  after- 
treatment,  differs  considerably.  As  Lord  Lister  pointed  out  long  ago, 
if  an  abscess  of  the  first  type  be  thoroughly  opened,  a  drainage  tube  of 
sufficient  size  inserted,  precautions  taken  not  to  let  in  fresh  organisms, 
and  the  wound  not  irritated  by  injections,  suppuration  ceases  at  once ; 
a  serous  discharge  takes  place  for  a  few  days  and  the  wound  heals 
rapidly.  In  these  cases  the  dressings,  as  a  rule,  should  be  changed  on  the 
following  day,  when  it  will  be  found  that  the  swelling  has  diminished 
considerably.  The  drainage  tube  should  not  be  removed,  for  if  this  were 
done  it  might  be  difficult  to  replace  it ;  but  if  it  is  being  pushed  forward 
the  retaining  stitches  should  be  cut  and  the  projecting  portion  of  tube 
removed.  A  fresh  dressing  is  then  applied,  the  orifice  of  the  wound 
and  the  skin  around  being  previously  washed  with  a  I  in  2000  sublimate 
solution.  The  question  as  to  when  the  dressing  should  be  changed  again 
will  be  determined  by  the  amount  of  discharge.  When  the  abscess  was 
originally  small,  the  second  dressing  can  usually  be  left  on  for  three  or 
four  days  ;  when,  however,  it  was  large,  and  there  is  much  serous  oozing, 
it  is  well  to  change  the  dressing  on  the  following  day.  In  most  cases  the 
drainage  tube  can  be  left  out  on  the  fourth  or  fifth  day ;  the  chief  factor 
which  determines  this  point  is  the  amount  of  serous  discharge  present. 
When  there  is  only  a  slight  discharge  there  need  be  no  hesitation  in  leaving 
out  the  tube ;  but  if  it  be  still  considerable,  or  purulent,  a  tube  long 
enough  to  extend  from  the  orifice  in  the  skin  to  the  entrance  of  the  abscess 
cavity  should  be  retained,  as  otherwise  the  skin  wound  may  close  with 
great  rapidity,  and  the  fluid  will  then  be  retained  in  the  interior,  and 
lead  to  reproduction  of  the  abscess. 

In  the  second  type  of  case  in  which  the  sepsis  is  more  acute,  and 
especially  in  those  in  which  organisms  such  as  the  bacillus  coli  are  present, 
the  discharge  remains  purulent  and  may  be  so  foul  and  toxic  that  further 
measures  are  necessary.  Whenever  it  is  feasible,  a  free  dependent  open- 
ing should  be  made  in  these  cases,  but  in  some,  especially  in  the  abdomen, 
this  may  not  be  possible.  Under  such  circumstances  it  may  be  advisable 
to  syringe  out  the  cavity  once  or  twice  daily.  Care  must  be  taken  to 
provide  a  free  exit  for  the  irrigating  fluid  so  as  to  avoid  any  risk  of  ruptur- 
ing the  abscess  wall.  The  ordinary  antiseptic  solutions  are  of  no  use 


DIFFUSE   CELLULITIS  31 

and  may  do  harm,  so  that  it  is  probably  better  to  use  sterile  salt  solution. 
When  the  discharge  is  foul,  however,  a  solution  of  peroxide  of  hydrogen 
(10  vols.i)  may  be  employed  with  benefit.  This  is  a  powerful  oxidising 
agent  and  has  also  the  useful  property  of  breaking  up  fragments  of 
blood-clot  and  soft  sloughs  and  bringing  them  away. 

In  some  cases  the  wound  can  be  cleaned  out  effectively  by  sucking  up 
the  discharge  through  a  piece  of  indiarubber  tubing  connected  to  a  syringe. 
This  is  specially  valuable  in  some  abdominal  abscesses  whose  walls  are 
made  up  of  adherent  coils  of  bowel  and  in  which  rupture  of  the  abscess 
wall  and  dissemination  of  the  pus  might  follow  irrigation. 

General. — The  general  treatment  of  acute  abscess  is  similar  to  that  of 
acute  inflammation  (see  p.  14).  As  soon  as  convalescence  begins,  nourish- 
ing diet,  fresh  air,  and  stimulants  are  necessary. 

DIFFUSE   CELLULITIS 

In  diffuse  cellulitis  the  pus  is  not  contained  in  a  well-defined  abscess 
cavity,  but  infiltrates  the  tissues.  This  condition  is  generally  due  to  the 
presence  of  the  streptococcus  pyogenes. 

SYMPTOMS. — The  tissues  are  infiltrated  with  pus,  and  portions  of 
them  often  die  and  come  away  afterwards  as  sloughs.  The  local  inflam- 
matory condition  spreads  rapidly,  and  the  skin  becomes  red  and  brawny. 
As  suppuration  occurs,  the  swelling  becomes  boggy,  but  it  is  difficult  to 
make  out  distinct  fluctuation — at  any  rate,  in  the  earlier  stages  ;  later  on, 
however,  it  is  not  uncommon  to  find  a  distinct  small  fluctuating  cavity 
in  the  infiltrated  area.  The  infection  spreads  along  the  lymphatic  vessels, 
so  that  red  lines  are  seen  extending  up  the  limb  to  the  nearest  lymphatic 
glands  quite  early  in  the  case.  As  the  infective  material  spreads  along 
the  lymphatic  vessels  it  not  infrequently  bursts  through  their  walls  at 
various  points,  leading  to  fresh  patches  of  diffuse  cellulitis.  It  is  not 
uncommon  for  the  condition  to  terminate  in  pyaemia. 

The  general  symptoms  accompanying  this  local  condition  are  very 
grave,  presenting  the  characters  of  asthenic  inflammatory  fever  (see  p.  3). 

THE  ATMBNT- — Local. — The  local  treatment  must  be  prompt  and 
radical,  and  must  aim  at  giving  free  and  early  exit  to  the  pus  and  sloughs. 
A  small  incision  can  do  no  good,  because  the  pus  is  infiltrating  the  tissues, 
and  could  not  escape  through  a  small  opening.  It  is  essential  that  the 
incision  should  be  free,  and  should  extend  right  through  the  whole  of 
the  inflamed  area.  If  one  incision  does  not  suffice  to  lay  the  whole  of  it 
open,  additional  ones  must  be  made  till  the  entire  area  has  been  incised. 
In  any  case  these  incisions  should  expose  the  deep  fascia  and  must  go 
even  deeper  if  necessary  ;  they  should  be  made  parallel  to  one  another 
and  to  the  great  vessels  of  the  part. 

After  the  incisions  have  been  made,  the  part  should  be  squeezed 

1  i.e.  one  volume  of  the  solution  will  yield  ten  volumes  of  oxygen. 


32  INFLAMMATION  AND  ITS  SEQUELAE 

gently,  and  any  recesses  from  which  pus  wells  out  should  be  thoroughly 
opened  up.  After  this  has  been  done,  very  satisfactory  results  are  often 
obtained  from  sponging  the  surface  of  the  wound  with  undiluted  carbolic 
acid  with  the  view  of  destroying  the  micro-organisms  if  possible.  The 
incisions  should  be  packed  for  a  day  or  two  with  strips  of  cyanide  gauze 
wrung  out  of  i  in  2000  sublimate  solution  and  sprinkled  with  iodoform, 
and  outside  them  an  ordinary  antiseptic  dressing  should  be  applied  (see 
p.  150). 

After-treatment — If  this  treatment  fails  to  bring  the  process  to  a 
standstill,  resort  should  be  had  to  constant  irrigation  or  to  a  water-bath, 


FIG.  9.— ^CONSTANT  IRRIGATION  BY  MEANS  OF  A  STRAND  OF  WORSTED.    The  method 
of  arranging  the  mackintosh  so  as  to  drain  off  the  fluid  is  also  shown. 

fresh  incisions  being  made  from  time  to  time  in  any  area  showing 
signs  of  extension  of  the  inflammation.  In  practising  irrigation  the 
apparatus  used  to  convey  the  fluid,  must  not  allow  the  latter  to  drop  on 
to  the  wound,  as  this  will  cause  intolerable  pain  in  a  very  short  time.  If 
a  tube  be  employed,  its  end  must  lie  upon  the  skin  at  the  highest  point  of 
the  wound.  Perhaps  the  best  plan  is  to  convey  the  fluid  to  the  wound 
by  means  of  capillary  action.  A  vessel  containing  the  lotion  is  placed 
at  a  higher  level  than  the  part,  and  a  strand  of  worsted  or  gauze  is  placed 
so  that  one  end  is  in  the  lotion,  while  the  other  lies  on  the  upper  part 
of  the  wound ;  the  fluid  runs  along  these  threads  very  quickly,  and  the 
wound  is  thus  constantly  washed  with  it  (see  Fig.  9).  The  liquid  used 
for  irrigation  should  be  at  or  slightly  above  the  temperature  of  the  body 
(i.e.  ioo°-io5°  F.),  and  this  can  be  arranged  for  by  keeping  a  night-light 
under  the  vessel  containing  it. 


DIFFUSE   CELLULITIS 


33 


It  is  well  to  add  some  antiseptic  to  the  irrigating  fluid,  but  it  is  im- 
portant to  avoid  those  which  precipitate  albumen  ;  otherwise  the  surface 
of  the  wound  becomes  coated  with  a  layer  of  coagulated  albumen, 
and  the  pus  and  organisms  will  accumulate  beneath  it  instead  of 
being  washed  away.  Perhaps  the  best  for  the  purpose  are  sanitas  (a 
teaspoonful  to  the  tumbler  of  water),  iodine  water  (a  teaspoonful  of  the 


FIG.  10. — CONSTANT  IRRIGATION.  The  method  of  forming  a  drain  for  the  surplus  fluid 
by  means  of  the  mackintosh  is  also  shown.  The  nozzle  of  the  irrigator  should  always 
lie  in  direct  contact  with  the  edge  of  the  sore. 

tincture  of  iodine  to  a  pint  of  water)  or  permanganate  of  potash  (two 
to  four  grains  to  the  ounce).  Care  must  be  taken  not  to  wet  the  bed, 
and  a  mackintosh  should  be  so  arranged  that  the  fluid  is  conducted  into 
a  basin  at  the  bedside  (see  Fig.  10).  If  possible,  it  is  well  to  have  the 
limb  suspended  over  an  empty  vessel,  but  in  any  case  a  piece  of  mackin- 
tosh should  be  arranged  beneath  it.  The  limb  should  be  raised  to  a 
higher  level  than  the  rest  of  the  body.  If  the  arm  be  affected,  it  may  rest 
upon  a  pillow  covered  with  a  mackintosh,  the  upper  end  of  which  is 
tucked  around  the  shoulders  of  the  patient,  and  the  sides  so  folded  that 
a  drain  is  formed  that  will  conduct  the  fluid  away  to  a  suitable  vessel 


34 


INFLAMMATION  AND  ITS  SEQUELAE 


at  the  bedside.  A  necessary  precaution  in  employing  irrigation  is  to 
prevent  the  neighbourhood  of  the  affected  part  becoming  sodden  with 
water,  and  in  order  to  avoid  this,  the  skin  around  should  be  smeared 
with  sterilised  grease  or  oil. 

Irrigation  should  be  continued  until  the  inflammation  has  ceased  to 
be  acute,  when  some  simple  dressing  should  take  its  place ;  otherwise 
the  granulations  are  likely  to  become  cedematous,  and  a  weak  or  cedema- 
tous  ulcer  is  formed  which  will  not  heal  properly.  An  excellent  dressing 
at  this  stage  is  eucalyptus  or  weak  boric  ointment  (half  the  strength 
of  the  pharmacopoeial  ointment)  spread  on  butter-cloth,  with  a  layer 
of  boric  lint  applied  outside.  The  protective  and  boric  lint  dressing 
described  in  the  treatment  of  ulcers  is  also  good  (see  p.  51). 


FIG.  ii. — WATER-BATH  FOR  LEG.  The  sloping  floor  of  the  bath  is  meant  for  the  leg 
to  rest  upon  :  it  is  better,  however,  to  have  holes  bored  through  the  sides  of  the  bath 
near  the  top,  to  which  can  be  fastened  slings  of  muslin  in  which  the  limb  rests.  The 
bath,  when  in  use,  is  covered  over  with  a  thick  blanket  to  maintain  its  temperature. 

Another  good  method  of  treatment  is  the  water-bath,  although  it  is 
hardly  so  satisfactory  as  irrigation.  In  irrigation,  the  secretions  being 
washed  away  as  rapidly  as  they  form,  no  nidus  remains  in  which  micro- 
organisms can  grow ;  in  the  water-bath,  the  discharges  are  not  washed 
away  so  rapidly,  but  they  are  diluted,  and  at  the  same  time  the  bath 
supplies  warmth  and  moisture.  If  an  antiseptic,  such  as  sanitas,  per- 
manganate of  potash,  boric  acid,  or  weak  iodine,  be  added  to  the  fluid, 
the  growth  of  the  organisms  is  inhibited  to  some  extent. 

The  limb  is  suspended,  by  means  of  a  large  gauze  or  muslin  sling,  in 
a  covered  bath  (see  Fig.  n),  filled  with  water  at  a  temperature  of  about 
100°  F.  containing  in  solution  one  of  the  antiseptics  mentioned  above. 
The  bath  should  be  furnished  with  a  tap  at  its  lowest  point,  and  a  gentle 
stream  of  water  should  flow  through  it  by  means  of  a  syphon  apparatus 
from  a  reservoir  above  the  level  of  the  limb  ;  the  water  in  this  reservoir 
should  be  kept  at  110°  F.  as  a  good  deal  of  heat  is  lost  as  the  fluid 
runs  through  the  tube.  The  skin  around  the  wound  should  be  rubbed 


DIFFUSE   CELLULITIS  35 

with  sterilised  oil.  The  water-bath  should  only  be  used  during  the 
day  ;  during  the  night  boric  lint,  wetted  with  hot  boric  lotion  and  covered 
with  mackintosh,  should  be  applied  to  form  a  fomentation.  The  bath 
requires  constant  attention  in  order  to  keep  the  water  warm,  to  prevent 
it  from  overflowing,  and  to  empty  it  from  time  to  time,  and,  therefore, 
the  patient  would  be  unable  to  get  proper  sleep  if  the  bath  were  employed 
during  the  night ;  moreover,  prolonged  soaking  in  warm  water  does  not 
improve  the  resisting  power  of  the  tissues.  When  the  feet  or  the  forearm 
are  affected,  a  water-bath  answers  very  well,  but,  in  the  latter  case,  the 
patient  must  be  propped  up  nearly  into  the  sitting  posture. 

When  the  upper  part  of  the  limb  or  the  trunk  is  affected,  the  patient 
must  lie  in  an  ordinary  bath  arranged  for  the  purpose.  Unless  the 
trunk  be  entirely  submerged,  special  precautions  must  be  taken,  by 
fastening  a  blanket  round  the  neck  and  covering  in  the  bath,  to  prevent 
the  patient  taking  cold. 

Care  must  also  be  taken  to  pre- 
vent the  water  in  the  bath  be- 
coming foul,  and  this  necessitates 
repeated  changing  of  its  contents. 
In  the  case  of  a  bath  in  which 
the  whole  patient  is  immersed, 
the  water  should  be  changed 
completely  three  or  four  times 
a  day,  or  more  often  if  there  is 
much  foul  matter  discharged  into 

it.       When    a    limb-bath     is    USed,        furnishedwithatap.asinFig.il. 

the  fluid  must  be  changed  every 

twelve  hours  and  the  bath  scrubbed  out.  Another  point  of  extreme 
importance,  especiaUy  in  hospital  practice,  is  the  necessity  for 
thorough  disinfection  of  the  bath  after  use.  The  cases  for  which 
this  method  of  treatment  is  employed  are  often  the  subjects  of 
an  infection  with  organisms  of  great  virulence,  some  of  which  are 
possessed  of  great  resisting  powers.  The  best  method  of  disin- 
fection is  to  immerse  the  bath  in  a  large  vessel,  such  as  a  copper 
and  boil  it ;  if  this  be  impossible,  the  bath  should  be  filled  nearly  full 
of  water,  covered  over,  and  supported  over  a  gas-ring  or  powerful 
spirit-stove,  so  that  the  water  and  steam  within  it  may  thoroughly 
disinfect  it.  A  mere  superficial  scrubbing  with  carbolic  acid— the  method 
that  is  most  commonly  employed— cannot  be  regarded  with  entire  satis- 
faction. If  sterilisation  by  boiling  be  inconvenient,  the  bath  may  be 
filled  with  a  strong  carbolic  solution  and  allowed  to  stand  for  twenty- 
four  hours.  All  baths  should  be  of  plain  metal  and  not  painted, 
varnished,  or  japanned. 

Moist  dressings  are  often  useful,  but  they  are  inferior  to  the  use  < 
irrigation  or  the  warm  bath.    They  consist  of  boric  lint  wrung  out  of 


36  INFLAMMATION  AND   ITS  SEQUELS 

Warm  boric  lotion  or  weak  sublimate  solution,  and  applied  over  the  whole 
surface  of  the  wound,  and  then  covered  with  a  piece  of  mackintosh 
extending  beyond  the  lint  in  all  directions.  This  requires  to  be  changed 
at  least  three  or  four  times  a  day,  when  the  wound  and  the  skin  around 
should  be  washed  with  a  i  in  2000  perchloride  solution. 

When  the  acute  symptoms  have  passed  off,  and  the  wounds  have 
become  reduced  to  simple  healing  sinuses,  an  antiseptic  dressing  of 
cyanide  gauze  and  wool  is  perhaps  the  best,  and  should  be  employed 
until  the  sinuses  have  contracted  down  and  there  are  only  flat  granulating 
sores  left.  When  the  wounds  are  quite  superficial,  there  is  no  objection 
to  the  employment  of  eucalyptus  ointment,  under  which  they  will  heal 


FIG.  13. — METHOD  OF  APPLYING  A  SPLINT  TO  THE  HAND  AND  FOREARM  IN  CELLULITIS. 
To  show  the  position  that  the  thumb  should  be  made  to  assume. 

rapidly.  The  ointment  should  be  spread  thickly  on  pieces  of  boric 
lint,  and  at  each  dressing  all  the  ointment  from  the  previous  application 
should  be  removed,  together  with  any  scabs  and  crusts  of  discharge. 
Ointment  should  not  be  used  as  a  dressing  over  the  mouth  of  a  deep 
sinus. 

Certain  other  points  in  the  local  treatment  of  diffuse  cellulitis  must 
be  attended  to.  It  is  of  primary  importance  that  the  part  should  be 
placed  absolutely  at  rest,  if  necessary  on  a  splint,  and  the  position  of  the 
limb  should  be  so  arranged  that,  should  stiffness  result,  as  it  is  apt  to 
do,  the  limb  will  be  in  the  position  most  convenient  for  the  patient.  For 
example,  in  the  case  of  the  hand,  the  fingers  should  not  be  extended, 
because  if  they  become  stiff  in  that  position  they  are  useless  ;  they 
should  be  about  half-bent  over  a  pad,  and  the  thumb  especially  should  be 
kept  apart  from  the  fingers,  and  allowed  to  drop.  If  the  thumb  be  kept 
at  the  same  level  as  the  fingers,  and  stiffness  result,  the  power  of  opposi- 
tion is  more  or  less  lost ;  whereas,  if  it  be  allowed  to  drop  below  the  level 


DIFFUSE   CELLULITIS  37 

of  the  fingers,  fairly  small  objects  can  be  picked  up  between  the  fingers  and 
thumb,  even  with  comparatively  limited  movement.  To  lay  the  whole 
hand  flat  on  a  splint,  with  the  thumb  at  the  side  of  the  fingers,  is  a  mistake 
so  commonly  made  that  too  much  attention  cannot  be  called  to  it.  The 
elbow  or  the  foot  should  be  put  up  at  a  right  angle,  the  knee  very  slightly 
flexed. 

Movement. — When  the  acute  inflammation  has  passed  off,  steps 
must  be  taken  to  prevent  stiffness  supervening,  for  in  diffuse  cellulitis, 
spreading  as  it  does  in  the  planes  of  the  cellular  tissue,  and  accompanied, 
as  it  often  is,  by  sloughing,  the  tissues  are  apt  to  become  adherent 
to  one  another.  Thus,  in  the  forearm,  owing  to  the  inflammation 
causing  adhesion  of  the  muscles  to  one  another,  and  owing  to  gan- 
grene of  portions  of  the  muscle  or  even  of  the  tendons,  the  hand  may 
become  permanently  useless.  Hence,  the  splint  must  be  given  up 
directly  the  acute  symptoms  have  passed  off,  and,  to  a  certain  extent, 
rapidity  of  healing  must  be  sacrificed  to  the  attempt  to  promote  move- 
ment. In  the  first  instance  passive  movements  only  are  attempted, 
and  these  are  combined  with  the  use  of  massage  (see  p.  23) . 

Active  movements  should  also  be  employed,  preferably  against  some 
form  of  resistance.  A  convenient  method  of  accomplishing  this  in  the 
case  of  the  forearm  and  hand  is  to  make  a  ball  of  Berlin  wool  about  the 
size  of  a  small  orange  and  to  instruct  the  patient  to  grasp  this  and  compress 
it  slowly  and  regularly  a  number  of  times  at  intervals  during  the  day. 
The  ball  of  wool  affords  a  comparatively  firm  but  elastic  article  to  grasp  ; 
its  size  and  tension  can  be  regulated  at  will.  The  patient  should  be 
encouraged  to  move  the  finger,  wrist,  and  elbow  joints,  two  or  three 
times  daily ;  in  addition,  massage  and  passive  movement  of  these 
joints  ought  also  to  be  practised  at  least  once  daily  on  the  lines  laid 
down  on  p.  23. 

In  bad  cases,  passive  movement  under  an  anaesthetic  may  be  required 
two  or  three  times  a  week,  but  care  must  be  taken  not  to  do  too  much 
at  a  time,  as  otherwise  fresh  effusion  may  be  caused,  and  the  object  of  the 
procedure  defeated. 

General. — Diffuse  cellulitis  is  a  very  grave  disease,  and  the  patient 
is  apt  to  pass  into  the  typhoid  state,  hence  free  stimulation  is  necessary. 
Perhaps  the  best  stimulant  is  brandy,  but  when  the  patient  is  very 
exhausted,  champagne  may  have  a  better  effect — at  any  rate,  tem- 
porarily. As  much  as  six  ounces  of  brandy  or  double  that  quantity  of 
champagne  may  be  administered  in  the  twenty-four  hours,  and  when 
the  pulse  is  very  weak,  an  even  larger  amount  may  be  necessary. 
Strychnine  injected  hypodermically  is  also  of  great  value.  Ten-grain 
doses  of  quinine  may  be  given  every  four  hours  till  marked  symptoms 
of  cinchonism  are  produced.  Easily  digested,  concentrated,  nourishing 
fluid  food  should  be  given  in  quantities  as  large  as  the  patient  can 
tolerate. 


38  INFLAMMATION  AND  ITS  SEQUELAE 

Anti-streptococcic  serum  has  been  used  frequently  of  recent  years  for 
this  affection.  Up  to  the  present,  however,  it  has  not  been  uniformly 
successful.  Information  concerning  this  remedy  will  be  found  on  p.  163. 
Vaccine  treatment  may  also  be  employed  (see  Appendix). 

The  essential  facts  to  remember  with  regard  to  diffuse  cellulitis  in 
general  are  the  rapidity  of  the  disease,  the  necessity  for  very  early  surgical 
intervention,  and  the  desirability  of  extremely  thorough  measures.  As 
a  matter  of  fact,  one  is  much  more  likely  to  do  too  little  than  too  much 
in  the  way  of  free  incisions. 

Diffuse  cellulitis  in  certain  special  situations,  e.g.  scalp,  neck,  etc., 
will  be  treated  of  in  their  appropriate  places. 


CHAPTER    III. 
ULCERATION. 

DEFINITION. — An  ulcer  has  been  roughly  denned  as  any  breach  of 
the  skin  or  mucous  membrane  which  does  not  tend  to  heal.  This  defini- 
tion, however,  includes,  not  merely  ulcers  proper,  the  result  of  inflammatory 
processes,  but  also  ulcerating  tumours,  with  which  we  shall  not  deal  in  the 
present  chapter.  True  ulceration  is  an  inflammatory  process,  and  a  more 
accurate  definition  is,  that  an  ulcer  is  a  progressive  loss  of  substance  in 
skin  or  mucous  membrane  which  has  been  the  seat  of  inflammatory 
changes  that  have  gone  on  to  granulation.  This  continued  loss  of  sub- 
stance is  not  due  to  death  of  visible  portions  of  tissue  (in  which  case  there 
would  be  gangrene),  but  to  degeneration  of  cells,  or  death  of  microscopic 
portions  of  the  tissue — what  is  known  as  molecular  death. 

CLASSIFICATION. — There  are  two  great  classes  of  ulcers  proper, 
namely  :  (i)  those  which  are  not  due  to  any  specific  virus,  but  are  caused 
by  various  local  troubles,  such  as  imperfections  in  the  blood-supply  or  the 
innervation  of  the  part — this  class  may  be  spoken  of  as  the  chronic  non- 
infective  ulcer ;  and  (2)  those  in  which  a  specific  virus  is  at  the  root  of  the 
ulcerative  process  ;  this  class  includes  a  large  group  of  ulcers,  by  far  the 
greater  number  being  the  result  of  syphilitic  or  tuberculous  disease,  and 
is  known  as  the  chronic  infective  ulcer.  In  them  there  is,  preceding  the 
ulcerative  process,  a  formation  of  new  tissue  which  has  a  special  tendency 
to  undergo  degeneration ;  for  example,  syphilitic  nodules  undergo  gum- 
matous  degeneration,  and  tubercles  undergo  caseation :  one  result  of  these 
changes  when  affecting  the  skin  is  ulceration.  These  chronic  infective 
ulcers  will  be  discussed  in  detail  in  connection  with  syphilis,  tubercle, 
etc.  ;  we  shall  only  deal  here  with  the  chronic  non-infective  ulcers  which 
result  directly  from  inflammation. 

CAUSES. — Before  proceeding  to  discuss  the  treatment  of  ulcers,  it  is 
necessary  to  consider  the  causes  which  lead  to  the  ulcerative  process,  and 
the  various  types  of  ulcers  they  produce.  The  causes  of  ulceration  are 
mainly  local,  and  among  the  chief  is  anything  which  tends  to  produce 

39 


40  INFLAMMATION  AND  ITS  SEQUELS 

defective  circulation  of  blood  in  the  part.  For  example,  if  an  inflamed  limb 
hangs  down,  the  return  of  the  venous  blood  is  impeded  ;  consequently,  less 
arterial  blood  flows  to  the  part,  and  its  nutrition  is  therefore  interfered 
with ;  this  is  the  explanation  of  the  fact  that  the  great  majority  of 
the  non-infective  ulcers  affect  the  lower  extremities.  In  addition  to  im- 
peding the  circulation  of  the  blood,  the  dependent  position  of  the  leg  acts 
also  by  producing  a  condition  of  lymph-stasis.  Were  the  arterial  and  venous 
channels  composed  of  a  rigid  and  unyielding  material,  the  dynamics  of  the 
circulation  would  be  unaffected  by  posture,  but  this  is  far  from  being  the 
case.  The  vessels  of  the  inflamed  part  are  already  leaky,  and  as  the  increased 
pressure  in  the  arterioles  due  to  the  weight  of  the  column  of  blood  in  the 
arteries  raises  the  capillary  pressure  upon  the  arterial  side,  and  as  the 
corresponding  column  of  blood  in  the  veins  increases  the  intra-capillary 
pressure  upon  the  venous  side,  an  increased  exudation  of  lymph  occurs 
through  the  endothelial  walls.  The  lymphatics,  like  the  other  vessels, 
are  acting  at  a  mechanical  disadvantage  and  hence  the  dependent  limb 
becomes  swollen,  and  the  vitality  of  its  tissues  is  markedly  lessened,  since 
they  are  supplied  with  stagnant  lymph. 

A  granulating  wound  on  the  leg  is  very  apt  to  become  the  subject  of 
an  ulcerative  process  if  the  patient  continue  to  stand  about  much,  or 
to  walk  on  the  leg,  or  even  to  hang  it  down.  Perhaps  one  of  the  most 
frequent  causes  of  ulceration  is  the  presence  of  varicose  veins,  especially 
when  the  veins  affected  are  the  small  tributaries  in  the  skin.  This  con- 
dition presents  a  very  marked  obstacle  to  the  venous  return ;  conse- 
quently there  is  stagnation  of  blood  and  the  nutrition  of  the  part  is 
impaired.  Again,  ulceration  may  result  from  imperfect  blood-supply 
apart  from  any  venous  obstruction,  as  is  seen  in  the  cases  in  which  there 
is  atheroma  of  the  arteries,  and  if  the  dependent  position  be  habitually 
assumed  in  the  presence  of  this  disease,  the  ulcerative  process  may  go  on 
rapidly.  This  imperfect  blood-supply  may  also  be  brought  about  by 
the  pressure  of  the  inflammatory  exudation  in  the  tissues  around  the  ulcer 
interfering  mechanically  with  the  circulation  of  blood  in  the  part.  This 
is  frequently  the  case  when  the  sore  is  situated  over  loose  connective 
tissue,  the  meshes  of  which  become  distended  with  lymph  and  which  is, 
moreover,  sparsely  supplied  with  blood-vessels. 

In  addition  to  these  causes  depending  upon  defective  circulation  of 
blood,  ulceration  is  greatly  favoured  by  a  feeble  condition  of  the  tissues, 
such  as  occurs  in  old  age.  A  wound  on  the  leg  in  a  young  person,  even 
though  he  be  the  subject  of  varicose  veins  and  still  continue  to  walk 
about,  is  not  nearly  so  likely  to  lead  to  an  ulcer  as  is  a  similar  injury  in 
an  old  person ;  to  a  great  extent  this  is  due  to  the  greater  vitality  and 
recuperative  power  of  the  tissues  in  the  young.  At  the  same  time,  in  old 
persons  there  is  generally  a  diminution  in  the  arterial  supply,  and  thus 
there  is  a  combination  of  at  least  two  of  the  causes  of  ulceration.  A 
similar  result  is  brought  about  by  anything  which  temporarily  enfeebles 


ULCERATION  41 

the  vitality  of  the  part,  such  as  severe  and  long-continued  exposure  to 
cold ;  when  not  severe  enough  to  produce  gangrene,  this  may  lead  to 
rapid  ulceration. 

A  very  frequent  cause  of  ulceration  is  difficulty  in  the  contraction 
of  the  sore.  When  a  wound  heals  by  granulation,  an  important  element 
in  the  healing  process  is  the  diminution  in  the  size  of  the  sore  from  the 
contraction  of  the  newly  formed  fibrous  tissue  ;  when  this  contraction 
cannot  occur,  a  time  will  come  when  healing  will  cease  and  ulceration  will 
take  place,  especially  if  the  sore  be  large.  The  constant  unsuccessful 
efforts  of  the  new  fibrous  tissue  to  contract  seem  to  irritate  the  part  and 
arrest  the  healing.  This  inability  to  contract  may  result  from  the  great 
size  of  the  sore,  from  its  adhesion  to  tissues,  such  as  a  bone  or  a  dense 
fascia,  which  do  not  permit  of  contraction,  or  from  induration  of  the 
margin  of  the  sore,  as  in  a  callous  ulcer.  Not  only  does  the  difficulty  in 
contraction  lead  to  ulceration  per  se,  but  the  new  tissue,  in  contracting, 
compresses  the  blood-vessels  going  to  the  part,  and  so  diminishes  the 
blood-supply. 

Again,  irritation  of  a  sore  may  lead  to  ulceration  instead  of  healing, 
either  mechanically,  as  by  pressure,  by  friction  of  the  dressings,  etc.,  or 
chemically,  as  by  irritation  due  either  to  the  lotions  used  in  the  treatment, 
(for  example,  carbolic  acid),  or  to  decomposing  secretions.  When  the 
discharge  from  a  sore  decomposes,  irritating  substances  are  formed  and 
may  lead  to  extensive  ulceration,  especially  if  they  do  not  escape  readily. 
This  is  most  often  the  case  when  the  discharge  dries  up  and  forms  crusts  ; 
under  these  crusts  this  decomposing,  irritating  secretion  accumulates,  and 
ulceration  occurs  instead  of  healing.  Hence  in  treating  an  ulcer  or  a 
septic  granulating  wound  it  is  of  great  importance  not  to  permit  the 
formation  of  crusts  or  scabs. 

Another  local  cause  which  leads  to  ulceration  is  movement.  When 
a  sore  is  situated  over  a  muscle,  or  over  a  fascia  which  is  in  frequent 
movement,  especially  if  it  be  adherent  to  either,  ulceration  is  more  likely 
to  occur  than  in  one  situated  elsewhere. 

Ulceration  may  also  be  set  up  by  accidental  contamination  of  the 
wound.  A  wound  which  is  healing  will  begin  to  ulcerate  if  virulent 
pyogenic  organisms  attack  it ;  they  lead  to  the  formation  of  an  inflam- 
matory ulcer.  Among  other  specific  infections  of  sores  may  be  mentioned 
diphtheria  and  phagedena,  the  latter  of  which  will  be  dealt  with  more 
fully  in  connection  with  gangrene. 

Ulcers  also  occur  in  parts  where  the  nervous  supply  is  imperfect — for 
example,  after  paralysis  or  neuritis.  Several  factors  may  come  into  play 
in  these  cases.  In  the  first  place,  if  a  limb  be  insensitive  to  pain,  exposure 
to  pressure  is  not  noticed  or  is  tolerated,  and  severe  ulcers  may  be  pro- 
duced before  the  patient  is  aware  that  anything  is  wrong.  In  these 
cases  the  ulcer  heals  readily  under  appropriate  treatment.  On  the 
other  hand,  in  lesions  of  the  spinal  cord,  as  in  infantile  paralysis,  or  in 


INFLAMMATION  AND   ITS  SEQUELS 


lesions  of  the  posterior  nerve  roots  and  ganglia,  such  as  locomotor  ataxy, 
the  ulcers  which  form  are  often  very  resistant  to  treatment,  although 
there  may  be  no  anaesthesia.  It  is  to  this  group  that  the  term  trophic 
ulcer  should  be  applied.  In  many  cases  there  are  anaesthesia  and  loss  01 
trophic  influence. 

Lastly,  ulcers  may  occur  in  connection  with  certain  constitutional  condi- 
tions, such  as  diabetes,  scurvy,  etc.  Diabetes  leads  to  ulceration,  partly 
from  the  diminished  blood-supply  due  to  the  endarteritis  which  so  often 
accompanies  it,  and  partly  from  the  increased  susceptibility  of  the  tissues 
to  septic  infection.  Scurvy  leads  to  extravasation  of  blood  into  the  tissues 
which  interferes  with  their  vitality,  and  often  ends  in  sloughing  of  the  skin. 

Signs  of  Healing. — It  is 
important  to  recognise  when 
a  sore  is  healing  and  when  it 
is  not.  When  a  portion  of 
tissue,  including  an  area  of 
skin,  has  been  removed  and 
a  wound  has  been  left,  the 
edges  of  which  cannot  be  ap- 
proximated, it  will  be  found 
after  a  few  days  that  the  wound 
has  commenced  to  heal  by 
granulation.  If  the  process  of 
repair  be  not  hindered  either 
by  the  occurrence  of  sepsis  or 
by  mechanical  irritation,  the 
granulations  fill  the  cavity  of 
the  wound  rapidly,  so  that  a 
flat  slightly  depressed  surface  is 
formed,  covered  with  bright- 
red  nodules  about  the  size  of 

a  millet-seed.  These  do  not  bleed  when  they  are  lightly  touched,  but  ooze 
freely  if  they  are  roughly  handled.  From  this  granulating  surface  comes 
a  small  amount  of  serous  discharge,  which,  on  microscopical  examina- 
tion may  be  found  to  contain  a  few  leucocytes,  but  the  fluid  does  not 
merit  the  name  of  pus.  At  the  edges  of  the  wound  the  epithelium  is 
found  spreading  inwards  ;  at  the  innermost  part,  where  there  is  a  single 
layer  of  epithelial  cells  covering  in  the  granulations,  the  presence  of  the 
epithelium  is  indicated  merely  by  a  flat  pink  zone  ;  beyond  this,  where 
the  epithelium  is  thicker,  there  is  a  distinct  bluish  line,  and  outside  this 
again,  a  zone  in  which  the  superficial  epithelial  cells  have  already  begun 
to  desquamate  and,  becoming  sodden  with  the  dressings  and  discharge 
from  the  wound,  form  a  white  line  around  it.  It  is  the  presence  of  the 
red  line  that  indicates  that  healing  is  actually  taking  place.  This  point 
can  best  be  made  out  by  drying  the  surface  of  the  ulcer,  when  it  will  be 


FIG.  14. — THE  APPEARANCES  PRESENTED  BY  A 
HEALING  ULCER,  (a)  Granulating  surface;  (6)  pink 
zone  of  epithelium ;  (c)  bluish  zone  of  thicker  epithe- 
lium ;  (d)  whitish  zone  of  desquamating  epithelium. 


ULCERATION 


43 


found  that  the  bare  granulating  surface  becomes  moist  again  at  once, 
while  the  red  line  around  remains  dry. 

VARIETIES. — Various  forms  of  ulcers  are  described,  of  which  the 
following  may  be  mentioned  : — 

Simple  Ulcer. — This  may  be  described  as  a  granulating  wound 
which  is  kept  from  healing  by  various  local  causes,  such  as  pressure, 
or  friction  from  the  dressings,  muscular  movements,  scratching,  inter- 
ference with  the  vascular  supply,  chemical  agencies,  and  so  forth.  In 
the  early  stage,  the  simple  ulcer  forms  a  flat  sore  covered  with  granu- 
lations of  a  yellow  or  brownish-red  colour,  on  a  level  with  the  surround- 
ing skin  or  only  slightly  depressed  below  it ;  its  margins  are  sharply  cut 
and  the  surrounding  parts  are  slightly  cedematous.  These  ulcers  extend 
fairly  rapidly  when  no  proper  care  is  taken.  In  certain  cases,  these 
and  other  ulcers  may  become  the  seat  of  acute  inflammation,  and  then 
we  have  the  second  form,  namely,  the  inflamed  ulcer. 

Inflamed  Ulcer. — This  is  an  ulcer  which  has  become  the  seat  of  acute 
inflammation,  as  the  result  of  some  mechanical  or  chemical  irritation, 
of  bad  methods  of  treatment,  or,  usually,  of  septic  infection.  The  sur- 
face of  the  ulcer  is  intensely  red  and  angry-looking,  it  bleeds  readily, 
secretes  a  large  quantity  of  pus,  extends  with  great  rapidity  and  is  not 
infrequently  covered  with  small  shreds  of  gangrenous  tissue  ;  the  skin 
around  is  bright  red  and  cedematous,  the  borders  are  irregular  and  eaten 
away,  and  it  is  not  uncommon  for  fresh  ulcers  to  develop  rapidly  around 
the  margin  of  the  original  sore.  These  fresh  ulcers  at  first  are  separated 
from  one  another  and  from  the  original  sore  by  bridges  of  skin,  which 
are  sometimes  quite  narrow,  intensely  inflamed,  swollen,  and  apt  to 
slough. 

Irritable  Ulcer. — This  form  of  ulcer  is  sometimes  met  with  in  neurotic 
women  as  a  small  sore  with  a  somewhat  elevated  surface,  and  intensely 
tender  to  the  slightest  touch.  It  commonly  occurs  about  the  external 
malleolus,  and  may  be  associated  with  menstrual  disorders.  A  similar 
ulcer  may  be  met  with  in  men,  but  very  rarely. 

Weak  Ulcer. — A  simple  ulcer  is  apt  to  become  a  weak  one  either 
from  too  small  a  quantity  of  blood  reaching  the  part,  or  from  deficient 
quality  of  the  blood,  as  for  example  when  ulcerations  occur  during  the 
progress  of  some  constitutional  disease.  There  are  various  kinds  of  weak 
ulcers,  depending  upon  the  cause  producing  them.  In  one  form,  the 
granulations  become  smooth  and  somewhat  yellowish,  the  secretions 
thin,  small  in  amount  and  very  apt  to  form  a  scab,  and  the  edges  pale  and 
flat.  In  a  second  form,  the  granulations  become  cedematous,  and  this 
usually  happens  in  connection  with  some  general  cause  of  oedema,  or 
some  local  interference  with  the  circulation,  especially  the  venous  return. 
In  a  third  form,  the  granulations  show  excessive  growth  ;  this  generally 
occurs  when  the  ulceration  is  due,  either  to  the  inability  of  the  sore  to 
contract,  or  to  irritation  from  the  materials  used  for  dressing.  In  such 


44  INFLAMMATION  AND  ITS  SEQUELS 

cases  the  granulations  become  prominent,  vascular,  soft,  and  bleed 
readily,  and  the  condition  is  popularly  known  as  '  proud  flesh.' 

Diphtheritic  and  Phagedenic  Ulcer. — Any  ulcer  may  be  attacked 
by  some  specific  virus,  such  as  that  of  diphtheria  or  that  which  produces 
phagedena.  In  the  latter  case  its  surface  becomes  covered  with  a  greyish, 
pulpy  material  which  rapidly  infiltrates  the  surrounding  skin  and  cellular 
tissue,  extends  both  superficially  and  deeply,  leads  to  extensive  and  very- 
rapid  destruction  and  constitutional  infection,  and  not  uncommonly 
ends  in  the  death  of  the  patient. 

Varicose  Ulcer. — This  is  a  type  of  ulcer  which  originates  in  connection 
with  varicose  veins,  especially  when  the  smaller  veins  of  the  skin  are 
affected.  This  condition  leads  to  imperfect  nutrition  of  the  skin,  and  to 
the  occurrence  of  either  a  local  dermatitis  ('  varicose  eczema ')  or  a 
periphlebitis  ending  in  the  formation  of  a  small  abscess  around  the 
vein  ;  the  abscess  bursts,  and  gives  rise  to  an  ulcer.  In  the  case  of  the 
eczematous  ulcer,  the  patient  usually  scratches  the  irritable  part  and 
produces  a  wound  which  becomes  inflamed  and  rapidly  develops  into 
an  ulcer.  However  produced,  these  varicose  ulcers  are  usually  small  and 
superficial  at  first,  with  oedema  around  and  with  soft,  prominent,  and 
somewhat  cedematous  granulations.  They  are  often  situated  immediately 
over  one  of  the  enlarged  veins,  and  the  ulcerative  process  occasionally 
extends  through  the  wall  of  the  vessel  itself.  In  this  way  a  severe 
haemorrhage  may  occur.  If  the  patient  continues  to  walk  about,  the 
condition  gradually  passes  into  that  of — 

Callous  Ulcer. — As  a  result  of  the  continued  interference  with  the 
venous  return,  local  oedema  takes  place  ;  there  is  exudation  of  coagulable 
lymph  in  the  interstices  of  the  cellular  tissue,  and  cells  accumulate  there. 
The  result  is  that  the  arterioles  are  pressed  upon,  and  the  nutrition  of 
the  sore  is  interfered  with.  The  exuded  material  coagulates,  and  becomes 
organised  to  a  considerable  extent  and  hence  the  skin  and  subcutaneous 
tissues  around  the  ulcer  become  thickened,  so  that  finally  the  surface 
of  the  ulcer  is  on  a  considerably  lower  plane  than  its  edge ;  this  is  not 
really  due  to  extension  of  the  ulcer  in  depth,  but  to  the  elevation  of  the 
surrounding  parts  owing  to  the  great  thickening  Thus,  the  characteristics 
ot  a  callous  ulcer  are  :  a  sore  at  a  deeper  level  than  the  surrounding  skin, 
an  indurated  condition  of  the  base  and  of  the  surrounding  parts,  and  a 
surface  of  a  pale  yellow  colour  devoid  of  granulation,  and  secreting  a 
small  quantity  of  thin  fluid.  These  ulcers  are  found  almost  exclusively 
among  the  labouring  class,  who  are  unable  to  obtain  the  rest  necessary 
for  their  cure. 

Haemorrhagic  Ulcer. — This  form  of  ulcer  occurs  especially  in 
patients  suffering  from  scurvy ;  the  surface  of  the  sore  is  red,  swollen, 
and  bleeds  readily,  and  the  blood  sometimes  coagulates  on  the  surface, 
forming  a.  firm  clot  which  has  been  likened  to  '  bullock's  liver.' 

Pressure  Ulcer. — This  form  of  ulcer  occurs  in  the  sole  of  the  foot, 


ULCERATION  45 

and  is  the  result  of  long-continued  but  not  necessarily  severe  pressure. 
The  pressure  leads  to  thickening  of  the  epidermis  and  the  formation 
of  a  callosity,  underneath  which  inflammation  and  suppuration  occur. 
When  the  thickened  epidermis  is  removed,  a  deep  sore  is  exposed,  with 
great  hypertrophy  of  the  skin  around  the  edge. 

The  Paralytic  Ulcer  occurs  in  connection  with  deficient  innervation 
especially  in  infantile  paralysis  and  after  injuries  to  nerves  In  paratysed 
limbs  it  is  not  uncommon  to  meet  with  atonic  ulcers  which  are  painless, 
quite  superficial  and  often  multiple.  As  a  rule  they  have  imperfect 
granulations  upon  the  surface,  and  most  commonly  occur  about  the 
phalanges  of  the  fingers  and  toes.  They  are  also  found  on  the  sole  of 
the  foot,  however,  and  in  this  situation  they  are  generally  ascribed  to 
pressure,  and  tend  to  assume  the  appearances  characteristic  of  pressure 
ulcers. 

In  connection  with  these  ulcers  due  to  pressure  upon  a  paralysed 
part,  the  so-called  perforating  ulcer  of  the  foot  deserves  special  notice.  It 
occurs  on  parts  exposed  to  marked  pressure,  and  is  chiefly  met  with 
beneath  the  heads  of  the  metatarsal  bones,  more  especially  that  of  the 
great  toe.  It  is  generally  seen  in  men  over  forty  who  have  much  stand- 
ing or  walking,  and  it  is  not  necessarily  connected  directly  with  any 
actual  paralytic  condition  of  the  limb,  but  is  supposed  to  result  from  a 
condition  of  peripheral  neuritis.  It  is  also  found  in  locomotor  ataxia 
and  diabetes.  The  affection  commences  as  a  callosity,  followed  by  in- 
flammation of  the  skin  underneath,  and  a  sore  forms,  resembling  at  first 
an  ordinary  pressure  ulcer  in  all  respects.  The  ulcer  extends  in  depth, 
without  any  great  superficial  increase  in  size,  becomes  more  or  less  funnel- 
shaped,  and  rapidly  penetrates  as  far  as  the  bone.  The  latter  may  then 
become  the  seat  of  a  rarefying  osteitis,  and  may  be  entirely  destroyed 
opposite  the  ulcer,  which  continues  to  increase  in  depth,  until  ultimately 
the  dorsum  of  the  foot  is  reached  and  a  complete  perforation  is  established. 
When  the  ball  of  the  toe  is  the  seat  of  the  affection,  the  metatarso-phalan- 
geal  joint  is  often  opened  and  destroyed.  The  base  of  the  ulcer  is  generally 
covered  with  reddish  warty  granulations,  the  skin  is  foul,  and  the  cavity 
of  the  ulcer  is  filled  up  with  a  dense  mass  of  epidermis,  which  undergoes 
decomposition.  In  some  cases  the  epidermis  spreads  down  the  sides  of 
the  ulcer,  and  in  many  there  is  marked  proliferation  of  it  around  the 
margins  of  the  sore. 

In  certain  constitutional  states,  such  as  diabetes,  ulcers  may  form. 
In  diabetes,  inflammation  or  ulceration  may  follow  the  slightest  scratch 
or  cut,  and  the  chief  characteristics  of  a  diabetic  ulcer  are  its  rapid  spread, 
the  presence  of  considerable  inflammation  around  it,  and  often  sloughing 
of  the  tissues.  The  endarteritis  which  occurs  in  diabetes  and  the  special 
liability  of  the  tissues  in  that  affection  to  septic  infection,  have  probably 
much  to  do  with  the  rapidity  of  spread  and  the  inflammatory  condition 
of  diabetic  ulcers. 


46  INFLAMMATION    AND  ITS  SEQUELS 

DANGERS  OF  ULCERS.— The  rapid  and  permanent  cure  of 
an  ulcer  is  a  matter  of  great  importance  ;  not  only  is  a  patient  afflicted 
with  an  ulcer  more  or  less  incapacitated  from  work,  but  he  is  liable  to 
various  accidents  which  may  permanently  cripple  him  or  even  lead  to 
his  death.  For  example,  when  an  ulcer  is  situated  over  a  muscular 
part,  the  muscles  may  become  so  matted  together  that  the  movements 
of  the  limb  are  much  interfered  with.  This  is  more  especially  the  case  if 
the  ulcer  lies  over  tendons ;  the  tendon  and  tendon-sheath  may  then 
become  adherent  to  one  another  and  to  the  surrounding  parts. 

Perhaps  the  most  common  disabilities  resulting  from  ulcers  are  those 
due  to  the  contraction  occurring  during  the  efforts  at  healing.  When 
an  ulcer  is  situated  over  a  joint,  for  example,  the  healing  process  may 
lead  to  so  much  contraction  as  to  fix  the  joint  permanently  in  a  faulty 
(usually  a  flexed)  position.  Again,  when  an  ulcer  surrounds  the  leg 
completely,  the  contraction  may  be  enough  to  constrict  the  vessels  coming 
from  the  parts  below,  and  so  cause  great  and  permanent  oedema  and 
often  complete  uselessness  of  the  foot.  A  further  risk  of  an  ulcer  is 
that  the  veins  in  its  vicinity  may  become  inflamed,  and  an  extensive 
simple  or  septic  phlebitis  may  follow.  A  patient  with  an  open  ulcer  is 
subject  to  all  the  ordinary  septic  diseases,  more  especially  erysipelas. 
Lastly,  it  may  be  pointed  out  that  epithelioma  not  infrequently  develops 
upon  an  ulcer  of  long  standing. 

TREATMENT. — Various  principles  must  be  attended  to  in  order 
to  promote  the  healing  process.  In  the  first  place,  it  is  essential  for  rapid 
healing  that  the  level  of  the  sore  should  be  nearly,  if  not  quite,  the  same 
as  that  of  the  surrounding  parts  ;  secondly,  its  margins  should  be  move- 
able,  in  order  to  permit  of  contraction  ;  and  thirdly,  the  granulations  on 
the  surface  should  be  healthy.  There  are,  therefore,  three  practical 
points  to  attend  to  in  the  treatment  of  ulcers:  (i)  To  remove  any 
cause  that  is  keeping  up  the  ulceration,  the  most  important  of  which 
have  already  been  mentioned ;  (2)  to  improve  the  condition  of  the 
surface  and  margins  of  the  ulcer ;  (3)  to  promote  healing  in  every 
possible  way,  and  to  provide  for  the  formation  of  as  sound  a  scar  as  can 
be  obtained. 

Removal  of  the  Cause. — The  first  essential  in  the  treatment  of 
all  ulcers,  is  to  seek  out  the  cause  and  remove  it ;  the  causes  have  been 
indicated  fully  in  the  preceding  paragraphs,  and  nothing  further  need  be 
said  about  them  here. 

Rest. — In  all  cases  rest  is  highly  desirable.  The  patient  must  be 
prohibited  from  walking,  and,  if  necessary,  the  movements  of  the 
neighbouring  joints  must  be  prevented  by  the  application  of  suitable 
splints.  If  splints  be  employed,  they  should  be  so  arranged  that  the 
limb  will  be  in  the  position  most  serviceable  to  the  patient  if  there  be 
any  subsequent  stiffness  either  of  joints  or  muscles.  For  example,  in 
the  case  of  the  leg,  on  which  ulcers  are  most  frequently  met  with,  it  is 


ULCERATION  47 

well  to  apply  a  splint  which  reaches  above  the  knee,  and  fixes  the  foot 
at  right  angles  to  the  leg. 

Promoting  the  Venous  Return. — The  danger  of  venous  obstruc- 
tion has  already  been  insisted  upon  ;  it  may  lead  to  the  transformation  of 
a  simple  or  varicose  ulcer  into  a  callous  one,  and  the  ulcer  will  refuse  to 
heal  as  long  as  no  provision  is  made  for  the  proper  return  of  blood  from 
the  affected  area.  This  indication  may  be  met  in  various  ways,  but  the 
most  efficient  is  to  place  the  part  on  a  higher  level  than  the  heart.  Patients 
who  are  suffering  from  ulcers  of  the  leg  should  be  put  to  bed  with  the 
limb  elevated  on  a  pillow,  and  the  knee  and  ankle-joints  fixed,  and  should 
not  be  allowed  to  get  up  for  any  purpose  whatever  until  cicatrisation  is 
complete.  Any  relaxation  of  this  rule  will  not  only  delay  the  healing 
of  the  ulcer,  but  may  lead  to  an  extension  of  the  ulceration.  When  the 
part  is  elevated,  the  venous  return  is  greatly  favoured,  and  the  exuda- 
tion which  has  been  poured  out  is  rapidly  absorbed  even  without  any 
other  treatment.  As  a  result,  the  pressure  upon  the  arterioles  going  to 
the  surface  of  the  ulcer  is  removed,  and  a  plentiful  flow  of  arterial  blood 
is  again  supplied  to  it.  Thus  rest  and  the  elevated  position  not  only 
favour  the  return  of  blood  from  the  part,  but  also  the  flow  of  blood  to  it. 

Promoting  Absorption  of  the  Exudation. — Measures  should  also 
be  taken  to  get  rid  of  the  exudation,  which  presses  on  and  interferes  with 
the  circulation  in  the  part.  The  elevated  position  and  rest  in  bed  are 
no  doubt  sufficient  to  do  this  of  themselves ;  but  if  time  be  an  object, 
various  measures  may  be  taken  to  accelerate  the  absorption  of  the  exuda- 
tion. Of  these,  one  of  the  best  is  massage.  When  massage  is  employed 
with  a  view  of  getting  rid  of  the  thickening  around  an  ulcer,  it  should 
be  applied  first  to  the  parts  above  the  ulcer ;  as  the  skin  gets  softer  in 
that  region,  the  area  subjected  to  the  massage  may  be  increased  down- 
wards. If  the  massage  were  applied  first  to  the  part  below  the  ulcer, 
the  absorption  would  not  be  satisfactory,  owing  to  the  presence  of  the 
exudation  above. 

Another  way  in  which  the  exudation  may  be  got  rid  of  is  by  pressure, 
and  this  is  especially  useful  when  patients  will  not  lie  up.  Pressure 
may  be  applied  in  two  ways  ;  either  by  strapping,  or  by  elastic  bandages. 
The  older  plan  was  to  use  strapping,  but  this  is  not  so  good  as  elastic 
pressure.  If  strapping  be  used,  strips  of  adhesive  plaster  are  applied 
fairly  tightly  around  the  ulcer  and  the  parts  in  its  vicinity.  These  strips 
should  be  rather  more  than  an  inch  broad  and  rather  longer  than  the  cir- 
cumference of  the  limb.  They  are  applied  from  below  upwards,  the  centre 
of  each  strip  being  applied  at  a  point  opposite  the  centre  of  the  ulcer, 
so  that  as  the  two  ends  are  brought  together  over  the  limb  they  pull 
the  edges  of  the  ulcer  together  (see  Fig.  15).  If  the  strips  were  applied 
with  their  centres  over  the  ulcer,  the  reverse  would  be  the  case ;  when 
they  were  pulled  tight  the  edges  of  the  ulcer  would  be  separated.  The  strips 
should  overlap  each  other  for  about  two-thirds  of  their  breadth,  so  that 


48 


INFLAMMATION  AND   ITS  SEQUELS 


only  about  a  third  of  each  is  exposed.  In  this  way  the  whole  region  of 
the  ulcer,  as  well  as  the  thickened  tissues  above  and  below,  are  firmly 
supported  and  pressed  upon  by  a  series  of  strips  of  adhesive  plaster 
applied  from  below  upwards.  Before  applying  the  strapping,  the  whole 
limb  should  be  shaved,  as  otherwise  great  annoyance  is  caused  to  the 
patient  when  it  is  peeled  off. 

One  great  objection  to  strapping  is  that  the  discharge  from  the  ulcer 
is  confined  beneath  it,  and  there  undergoes  decomposition,  and 
consequently  fresh  ulceration  occurs.  The  ulcer,  therefore,  should  be 


FIG.  15. — METHOD  OF  STRAPPING  AN  ULCER.    A  dressing  has  been  applied  over 
the  ulcer,  which  is  represented  by  a  dotted  outline. 

disinfected  before  the  strapping  is  applied,  and  boric  lint  should  be  placed 
over  its  surface  so  as  to  absorb  and  prevent  the  decomposition  of  fluids. 
Unless  this  be  done,  it  will  be  necessary  to  cut  away  the  lower  parts  of  the 
strapping  so  as  to  allow  the  discharge  to  escape,  a  procedure  which 
necessarily  weakens  it.  The  strapping  should  be  renewed  every  second 
day  unless  there  is  much  discharge,  when  it  must  be  renewed  daily. 

Strapping  has  now  been  largely  abandoned  in  favour  of  the  elastic 
bandage,  that  known  as  Martin's  being  the  most  suitable  form.  Martin's 
bandage  is  a  thin  sheet  of  pure  rubber,  cut  into  strips  about  three  inches 
wide  and  of  varying  lengths  ;  this  is  wound  around  the  limb,  commencing 
at  the  ball  of  the  toes  and  extending  up  as  far  as  the  knee.  The  best  form 
is  that  containing  a  number  of  perforations  to  permit  of  evaporation  ; 
otherwise  the  perspiration  accumulates  beneath  the  bandage  and  may 
set  up  a  dermatitis. 


ULCERAT10N  49 

The  above  methods  of  applying  pressure  are  only  continued,  in  the 
case  of  patients  who  can  afford  the  time  to  lie  up,  until  the  exudation 
has  become  absorbed.  If  continued  longer,  they  interfere  with  the 
nutrition  of  the  limb. 

Another  method  of  getting  rid  of  the  exudation  accompanying  a 
callous  ulcer  is  the  application  of  blisters.  When  a  blister  is  applied  to 
the  skin,  more  blood  is  sent  to  the  part  and  the  lymph  flow  is  increased  ; 
if  a  blister  be  applied  around  a  callous  ulcer  (the  limb  meanwhile  being 
kept  at  rest  in  the  elevated  position),  it  is  remarkable  how  quickly  the 
callous  condition  disappears,  and  the  edges  become  soft  and  in  a  condition 
favourable  for  healing. 

The  essential  point  in  employing  a  blister  in  the  treatment  of  an 
ulcer  is  that  it  should  not  be  applied  directly  over  the  raw  surface,  other- 
wise the  cantharides  is  apt  to  be  absorbed,  and  may  lead  to  serious 
irritation  of  the  kidneys.  This  must  be  borne  in  mind  in  cases  of  callous 
ulcer  especially,  for  many  of  the  patients  suffering  from  this  affection 
are  the  subjects  of  Bright's  disease.  Hence,  the  blister  should  be  raised 
round  the  margin  of  the  ulcer  only  ;  the  surface  of  the  ulcer  should  not 
be  allowed  to  come  into  contact  with  the  cantharides.  For  the  method 
of  application  of  blisters,  see  p.  19.  Usually  one  blister  will  suffice, 
and  it  will  be  found  that,  by  the  tune  the  blistered  surface  has  healed, 
the  callous  condition  of  the  ulcer  has  disappeared,  and  its  edges  are  in 
a  satisfactory  condition. 

Avoidance  of  Irritation — Another  important  point  in  the  treat- 
ment of  all  ulcers  is  to  get  rid  of  anything  that  irritates  the  surface  of 
the  sore.  The  irritation  may  be  mechanical,  such  as  that  caused  by 
dressings  applied  directly  to  the  surface  of  the  sore,  or  chemical,  such  as 
unsuitable  lotions  or  decomposing  discharges  ;  the  chemical  causes  are 
the  more  common.  In  order  to  avoid  mechanical  irritation,  the  dressing, 
whether  it  be  gauze  or  boric  lint,  should  not  be  applied  directly  to  the 
surface  of  the  sore,  but  oiled  silk  protective  or  an  antiseptic  ointment 
should  be  interposed. 

A  most  important  point  is  the  avoidance  of  chemical  irritation  either 
from  lotions  or  decomposing  discharges.  The  lotions  used  should 
be  antiseptic,  but  irritating  antiseptics,  such  as  strong  carbolic  acid, 
should  not  be  selected. 

Disinfection  of  the  Ulcer. — The  presence  of  decomposing  discharge 
on  the  surface  of  an  ulcer  interferes  materially  with  the  healing  process, 
and  it  is  therefore  most  important  to  remedy,  as  far  as  possible,  the 
septic  condition  of  the  sore  at  the  commencement  of  the  treatment.  In 
order  to  do  this,  we  recommend  the  following  method  of  procedure.  In 
the  first  place,  the  skin  should  be  disinfected  for  a  considerable 
area  around  the  ulcer.  Disinfecting  the  surface  of  the  ulcer  alone  and 
leaving  the  skin  septic  simply  means  that  the  surface  will  again  become 
infected  in  a  few  days.  Therefore  the  skin  should  be  thoroughly 


50  INFLAMMATION  AND  ITS  SEQUELS 

washed  with  ether  soap  and  a  disinfecting  lotion,  and  shaved.  The 
best  lotion  to  use  for  the  purpose  is  a  I  in  20  watery  solution  of  carbolic 
acid  in  which  is  dissolved  one  five-hundredth  part  of  corrosive  sublimate  ; 
this  will  be  referred  to  hereafter  as  '  strong  mixture.'  The  lotion  can  be 
conveniently  prepared  by  adding  to  a  pint  of  i  in  20  carbolic  acid  two 
soloids  of  perchloride  of  mercury  of  the  usual  strength  (875  gr.).  It 
should  be  noted  that  '  strong  mixture '  cannot  be  made  by  mixing  equal 
parts  of  i  in  20  carbolic  and  I  in  500  perchloride  of  mercury  lotions. 

The  part  is  first  thoroughly  washed  with  soap  and  this  mixture,  and 
then  well  scrubbed  with  a  nail-brush  dipped  in  the  mixture ;  finally,  the 
strong  mixture  may  be  removed  from  the  skin  by  washing  it  with  a 
i  in  2000  watery  solution  of  corrosive  sublimate.  It  is  not  always  easy 
to  disinfect  the  surface  of  an  ulcer  completely  at  one  sitting ;  the  most 
rapidly  efficacious  plan  seems  to  be  to  swab  it  thoroughly  over  with 
undiluted  carbolic  acid.  A  small  piece  of  sponge  is  dipped  in  liquefied 
carbolic  acid,  rubbed  firmly  over  the  whole  surface  of  the  granulations 
and  sides  of  the  ulcer  and  allowed  to  act  for  some  minutes.  This  no 
doubt  destroys  the  granulations,  but  they  are  usually  unhealthy,  and  of 
no  use  in  healing  ;  the  method  is  a  very  effectual  one.  The  application 
causes  a  good  deal  of  pain  at  the  time,  but  this  soon  passes  off,  for  the 
acid  is  a  local  anaesthetic.  When  the  granulations  are  prominent,  or 
soft  and  cedematous,  it  is  well  to  scrape  them  away  with  a  sharp  spoon  ; 
if  the  ulcer  be  large  a  general  anaesthetic  is  necessary. 

Other  methods  of  purifying  the  ulcer  have  been  employed.  Lord 
Lister  used  to  apply  a  solution  of  chloride  of  zinc  (40  gr.  to  the  ounce  of 
water).  This  however  is  much  more  painful  than  the  application  of  the 
undiluted  carbolic  acid,  the  pain  lasting  for  hours,  while  the  method  does 
not  seem  to  be  so  efficient. 

When  it  does  not  seem  desirable  to  employ  undiluted  carbolic  acid, 
disinfection  of  the  sore  may  be  obtained  by  packing  the  surface  with  lint 
dipped  in  i  to  5  carbolic  oil ;  if  this  be  changed  twice  a  day,  the  foul 
condition  will  usually  be  got  rid  of  in  the  course  of  two  or  three  days. 
The  oil  should  be  applied  to  the  surface  of  the  ulcer  alone  ;  if  applied 
to  the  skin  it  may  produce  much  irritation. 

First  Dressing  after  Disinfection. — The  best  dressing  to  employ  after 
the  disinfection  is  cyanide  gauze  and  salicylic  wool,  as  used  in  the  treat- 
ment of  wounds  (see  Chap.  V.).  The  gauze  should  be  soaked  in  i  in  4000 
sublimate  solution  and  applied  directly  to  the  surface  of  the  ulcer,  and 
the  salicylic  wool  i  is  put  on  outside  the  gauze.  When  there  is  any  doubt 
as  to  the  completeness  of  the  disinfection,  it  is  well  to  pack  the  recesses 
of  the  ulcer  with  small  pieces  of  cyanide  gauze  lightly  squeezed  out  of 
i  in  2000  sublimate  solution. 

1  Although  these  medicated  wools  may  be  applied  outside  the  gauze  dressings 
just  as  they  are  taken  from  the  packages  in  which  they  are  sold,  it  is  an  undoubted 
advantage  to  subject  them  to  the  action  of  superheated  steam  if  possible  (see  p.  97). 


ULCERAT1ON  51 

Boric  Lint  and  Protective  Dressing. — After  two  or  three  days,  when  it  is 
clear  that  asepsis  has  been  obtained,  and  the  tissues  are  getting  into  a  more 
healthy  condition,  the  use  of  gauze  should  be  given  up,  and  unirritating 
dressings  and  lotions  employed.  A  saturated  watery  solution  of  boric 
acid  is  an  excellent  lotion,  while  the  protective  and  boric  lint  dressing 
introduced  by  Lord  Lister  is  as  good  a  dressing  as  can  be  employed. 
In  this  method  the  surface  of  the  ulcer  is  washed  with  boric  lotion,  and 
a  piece  of  protective  (oiled  silk  covered  with  a  layer  of  dextrin)  is  soaked 
in  carbolic  lotion  (i  in  20),  and  then  dipped  in  boric  lotion  to  wash  away 
the  acid,  and  applied  over  the  wound.  The  protective  should  overlap 
the  sore  in  all  directions,  but  ought  not  to  extend  too  far  beyond  its  edge, 
as  otherwise  sepsis  may  spread  in  beneath  it.  Outside  the  protective, 
pieces  of  boric  lint,  wrung  out  of  boric  lotion,  are  wrapped  around  the 
limb,  overlapping  the  protective  to  a  considerable  extent  in  all  directions. 
This  dressing  should  be  changed  daily  for  the  first  few  days  ;  and  every 
second  or  third  day  the  skin  around  should  be  washed  with  carbolic 
lotion  (i  in  20),  which  must  not  be  allowed  to  run  on  to  the  sore.  The 
limb  should  be  shaved  at  least  once  a  week.  If  there  be  much  discharge, 
holes  should  be  cut  in  the  centre  of  the  protective  so  as  to  allow  it  to 
drain  into  the  lint. 

Wet  Boric  Dressing. — When  the  ulcer  is  painful,  or  when  there  are 
sloughs  on  its  surface,  wet  boric  lint  should  be  applied  without  any 
protective,  the  lint  being  used  in  the  same  way  as  a  water  dressing.  The 
boric  lint  is  soaked  in  hot  boric  lotion  and  applied  over  the  ulcer  so 
as  to  extend  well  beyond  it,  and  outside  this,  overlapping  it  in  all 
directions,  is  fastened  mackintosh,  oiled  silk,  or  guttapercha  tissue,  pre- 
viously disinfected  by  boiling,  or  by  immersion  in  carbolic  lotion.  This  wet 
boric  dressing,  fomentation  or  poultice,  as  it  is  sometimes  called,  should 
be  changed  twice  a  day,  but  should  not  be  continued  after  the  irritable 
condition  of  the  sore  has  ceased,  or  after  the  sloughs  have  separated.  If  it 
be  continued  too  long,  the  granulations  become  oedematous  and  a  form 
of  weak  ulcer  is  established. 

Boric  Ointment. — Antiseptic  ointments  are  especially  useful  when  the 
ulcers  are  healing  rapidly  ;  zinc  ointment,  which  is  commonly  employed, 
is  very  objectionable  on  account  of  its  septicity.  The  most  generally 
useful  ointment  is  either  unguentum  acidi  borici  or  unguentum  eucalypti. 
The  boric  ointment  of  the  Pharmacopoeia,  however,  will  be  found  to  be 
too  strong  to  permit  rapid  healing,  and,  in  most  cases,  one  of  half  its 
strength  is  the  most  suitable.  This  should  be  spread  thinly  and  evenly 
on  muslin  or  butter-cloth,  no  portion  of  the  surface  being  left  uncovered 
by  the  ointment ;  a  piece  of  boric  lint  is  applied  outside  and  the  whole  is 
secured  by  a  bandage. 

Cases  are  sometimes  met  with  in  which  the  surface  of  the  sore  is 
very  delicate  and  seems  to  resent  the  presence  of  any  application,  how- 
ever unirritating  it  may  be ;  as  long  as  anything  is  in  contact  with  it, 

E  2 


52  INFLAMMATION  AND  ITS  SEQUELS 

cicatrisation  will  not  take  place.  Under  these  circumstances,  the  best  plan 
is  to  dispense  with  dressings  entirely  and  merely  to  place  over  the  ulcer 
some  contrivance  that  will  prevent  anything  coming  into  contact  with 
its  surface.  This  may  be  accomplished  by  fixing  over  it  a  perforated 
celluloid  shield  (see  Fig.  16)  of  suitable  size  and  shape,  or  a  wire  cage 
moulded  to  fit  the  limb,  leaving  the  granulating  surface  bare.  The 
shield  should  be  removed  two  or  three  times  daily,  and  the  raw  surface 
washed  with  boric  lotion  to  remove  any  discharge.  The  limb  should 
be  fixed  in  the  elevated  position,  and  the  surrounding  skin  should  be 
disinfected  previously  as  recommended  above.  If  a  wire  cage  be  used,  the 
limb  should  be  slung  in  a  cradle  and  the  cage  surrounded  by  a  dressing. 
If  there  be  much  tendency  to  the  formation  of  crusts  from  the  drying  of 
the  discharge,  a  moist  dressing  may  be  applied  outside  the  shield  to 


FIG.  16. — CELLULOID  WOUND-SHIELDS.  The  shield  is  inserted  in  the  centre  of  a  sheet 
of  adhesive  plaster,  by  means  of  which  it  is  applied  to  the  limb.  In  the  figures,  two  holes 
are  represented  in  each  shield  ;  these  are  to  permit  of  evaporation.  If  it  be  desired  to 
keep  the  surface  of  the  ulcer  quite  moist,  non-perforated  shields  may  be  used. 

prevent  evaporation.  A  piece  of  gauze,  soaked  in  boric  lotion  and 
covered  with  mackintosh,  will  suffice.  In  some  cases  Bier's  treatment 
is  of  value  ;  this  method  has  already  been  described  on  p.  13. 

Skin-grafting  to  obtain  a  Sound  Scar. — A  very  important  object 
in  the  treatment  of  all  ulcers  is  to  obtain  a  sound  scar.  In  the  ulcers 
affecting  the  lower  extremity  in  elderly  people,  the  scar  resulting  from 
spontaneous  healing  is  weak,  and  readily  breaks  down  if  the  patient  does 
much  standing  or  walking.  The  patient  is  therefore  frequently  obliged  to 
give  up  work  in  order  to  get  the  ulcer  re-healed,  or  must  be  content 
to  employ  means  which  merely  prevent  the  extension  of  the  ulcer,  and 
give  relief  from  some  of  the  discomfort.  When  the  best  possible  scar 
is  desired,  and  when  it  is  important  to  avoid  great  contraction,  it  is 
necessary  to  adopt  some  method  of  skin-grafting.  There  are  three  plans 
by  which  rapid  healing  of  a  sore  may  be  brought  about :  Reverdin's 
epidermis  grafting,  Thiersch's  skin-grafting,  and  the  use  of  the  whole 
thickness  of  the  skin ;  of  these  the  best  in  our  opinion  is  that  employed 
by  Thiersch. 

In  Reverdin's  method  small  thin  portions  of  the  superficial  layer 
of  the  skin  are  snipped  off  with  curved  scissors.  Pieces  about  the  size 
of  a  hemp-seed  are  planted  on  the  surface  of  the  granulations  at  short 


i  0    -  fj  3  J  _ 
• 


ULCERATION  53 

distances  from  each  other  ;  epidermic  growth  occurs  from  each  of  these 
little  points,  and  the  result  is  that  numerous  small  islands  of  epithelium 
form  over  the  surface  of  the  sore.  If  the  grafts  be  close  enough  together 
and  the  conditions  be  favourable  to  healing,  these  islands  soon  coalesce, 
and  thus  rapid  cicatrisation  is  obtained.  These  grafts  should  not  be  too 
far  apart,  because  they  appear  to  have  only  a  limited  power  of  repro- 
duction. Each  graft  usually  gives  rise  to  an  island  of  epidermis  about 
the  size  of  a  sixpence,  and  then  growth  seems  to  come  to  a  standstill.  The 
result  of  this  method  of  epidermic  grafting  is  that  rapid  healing  is  obtained 
in  many  cases,  especially  in  burns  and  sores  on  the  trunk,  where  the  skin 
is  freely  movable  over  the  deeper  parts.  The  contraction  of  the  subse- 
quent cicatrix  is  considerably  diminished  thereby,  because  less  granu- 
lation tissue  is  formed  than  if  the  sore  had  to  heal  altogether  from  the 
margin,  for  the  amount  of  contraction  depends  entirely  on  the  amount 
of  young  granulation  tissue  produced.  Nevertheless,  considerable  con- 
traction will  inevitably  occur  where  healing  has  been  obtained  in  this 
way,  and  the  resulting  scar  is  not  materially  stronger  than  that  obtained 
by  permitting  the  sore  to  heal  from  the  edge. 

With  a  view  of  obtaining  a  sounder  scar,  thicker  and  more  extensive 
portions  of  the  skin  must  be  taken,  and  the  grafts  must  be  applied  close 
together.  There  are  two  ways  of  doing  this :  either  by  using  the  whole 
thickness  of  the  skin,  or  by  employing  Thiersch's  method,  in  which  about 
half  the  thickness  of  the  skin  is  shaved  off.  We  need  not  describe  the 
procedure  where  the  whole  thickness  of  the  skin  is  employed,  partly 
because  the  results  are  not  satisfactory,  and  partly  because  all  the 
conditions  for  which  it  was  introduced  are  better  fulfilled  by  Thiersch's 
method.  Skin-grafts  can  be  taken  either  from  the  patient  himself  or 
from  a  second  individual.  When  the  patient  is  very  debilitated,  the 
cutaneous  epithelium  shares  in  the  general  malnutrition,  and  under  these 
circumstances  a  graft  from  a  healthy  subject  might  succeed  better  than 
one  taken  from  the  patient. 

Thierseh's  Method. — In  employing  Thiersch's  method,  the  skin  which 
is  to  be  used  for  the  grafting  must  first  be  shaved  and  disinfected  in  the 
usual  manner  (see  p.  50).  The  presence  of  hairs  on  the  grafts  seems  to 
interfere  materially  with  their  union. 

Preparation  of  the  Ulcer. — (a)  Preliminary. — It  is  of  no  use  to 
graft  a  sore  which  is  actually  ulcerating ;  it  must  be  brought  into  a 
healthy  condition,  and  healing  must  have  commenced  before  grafting  is 
likely  to  be  successful.  The  best  criterion  that  healing  is  taking  place 
is  the  presence,  at  the  edges,  of  the  dry  red  line  which  indicates  recently 
formed  epithelium.  Some  surgeons  wait  for  a  considerably  longer  time 
before  grafting,  in  order  to  get  a  firm  layer  of  granulations ;  but  our 
experience  is  that  the  sore  may  be  safely  grafted  upon  as  soon  as  healing 
begins  around  the  edge.  A  second  essential  is  that  the  sore  shall  be 
clean.  If  the  discharges  be  septic,  the  graft — which  is  after  all  merely 


54  INFLAMMATION  AND   ITS  SEQUELS 

a  piece  of  dying  tissue — will  become  impregnated  with  decomposing  pus, 
and  may  rapidly  become  loosened,  die,  and  undergo  decomposition.  The 
methods  of  rendering  the  ulcer  aseptic  have  already  been  described  (see 
p.  49). 

(b)  Operative. — The  following  is  the  method  of  procedure.  The 
patient  is  put  under  an  anaesthetic,  and  the  granulations  over  the  whole 
surface  of  the  ulcer  are  forcibly  scrubbed  off  with  a  firm  nail-brush  or 
are  evenly  scraped  away,  taking  care,  however,  only  to  remove  the  soft 
layer  of  granulations  and  not  to  go  through  the  deeper  one  of  newly 
formed  fibrous  tissue  into  the  fat.  A  surface  is  thus  left  which  is  smooth, 
highly  vascular,  and  firm,  and  consists  of  the  deeper  layers  of  granula- 
tion tissue  which  have  already  become  organised  into  fibrous  tissue. 
In  the  case  of  ulcers  on  the  lower  extremity,  it  is  also  advisable  to 
remove  those  portions  of  the  edge  which  have  already  become  covered 
with  new  epithelium.  If  the  grafting  be  limited  to  the  parts  actually 
unhealed,  the  result  is  disappointing,  as  a  rule ;  for,  while  the  part  grafted 
remains  sound,  the  margin  where  spontaneous  healing  had  occurred  is 
apt  to  break  down,  and  thus  a  narrow  line  of  ulceration  appears  at  the 
site  of  the  edge  of  the  ulcer. 

After  the  layer  of  granulations  has  been  removed  and  the  newly 
healed  edge  of  the  ulcer  has  been  cut  away,  the  bleeding  must  be 
arrested  completely  before  the  grafts  are  applied.  The  most  rapid 
method  is  to  pour  a  few  drops  of  adrenalin  chloride  (i  in  1000) 
solution  over  the  raw  surface,  when  the  oozing  ceases  immediately.  If 
adrenalin  be  not  at  hand  the  following  plan  will  be  found  satisfactory. 
Any  spouting  vessel  is  clamped,  and  a  large  piece  of  sterilised  protective 
(see  p.  51)  or  thin  sheet-rubber  is  applied  over  the  raw  surface.  Outside 
this  several  sponges  are  placed,  and  a  sterilised  bandage  is  bound  firmly 
over  them  ;  if  the  sore  be  small  and  an  assistant  be  available,  he  may 
apply  the  pressure.  Pressure  is  employed  indirectly  through  the  pro- 
tective in  this  way,  because  if  it  were  made  directly  upon  the  surface  of 
the  wound  by  means  of  sponges,  bleeding  would  recommence  when  the 
latter  were  removed,  as  they  stick  to  the  raw  surface. 

Cutting  the  Grafts.  —While  the  bleeding  is  being  arrested,  the  surgeon 
cuts  his  skin-grafts  from  any  part  of  the  body  that  he  thinks  fit ;  as  a 
rule  they  are  taken  from  the  front  of  the  thigh,  but  the  side  of  the 
abdomen  may  be  made  use  of  when  the  grafts  are  to  be  applied  to 
the  face.  The  area  from  which  the  grafts  are  to  be  cut  is  disinfected 
(see  p.  49)  and  the  surgeon  grasps  the  limb  from  behind  with  his  left 
hand  in  such  a  way  as  to  make  the  skin  over  the  front  of  the  limb  as 
tense  as  possible  ;  in  doing  this  he  pushes  the  soft  parts  well  forward  so 
as  to  make  the  anterior  aspect  of  the  limb  as  flat  as  possible.  The  skin  is 
further  put  on  the  stretch  vertically  by  an  assistant  who  pulls  it  upwards 
and  downwards  (see  Fig.  17).  These  precautions  are  important,  as, 
without  them,  it  is  almost  impossible  to  cut  a  graft  of  even  width.  The 


ULCERATION 


55 


razor  (see  Fig.  18),  which  should  have  a  very  broad  blade,  is  dipped 
in  boric  lotion  and  is  kept  constantly  wet  by  this  solution  whilst  the 
grafts  are  being  cut,  just  as  in  making  microscopical  sections  of  fresh 
tissues.  Unless  this  be  done,  the  graft  adheres  to  the  blade  and  may  be 
either  partially  or  wholly  cut  through  before  a  sufficient  length  has  been 
obtained.  The  razor  is  made  to  penetrate  through  about  half  the  thick- 


FIG.  17. — THIERSCH'S    METHOD    OF    SKIN-GRAFTING.      Cutting    the    grafts.     The  figure 
is  intended  to  show  how  the  parts  are  steadied  while  the  grafts  are  being  cut. 


FIG.  18. — THIERSCH'S  RAZOR  FOR  SKIN-GRAFTING.  The  instrument  is  wholly  metal 
and  can  be  got  with  a  blade  of  any  width.  The  wider  the  blade  the  better  can  long, 
wide  grafts  be  cut. 

ness  of  the  skin,  and  then,  by  a  lateral  sawing  motion,  the  grafts  are  cut 
as  broad  and  as  long  as  possible.  After  a  little  practice  it  is  easy  to  cut 
grafts  about  two  inches  in  breadth,  and  four  or  five  in  length.  If  one 
graft  be  insufficient,  it  is  best  to  slide  it  off  the  razor  and  leave  it  lying 
on  the  bleeding  surface  ;  in  this  way  it  is  kept  warm  and  moist.  Some 
surgeons  put  the  graft  into  warm  sterilised  saline  solution,  and  it  is  then 
said  to  spread  out  more  easily  afterwards.  Small  skin-grafts  can  be  cut 
under  local  anaesthesia.  For  this  purpose  a  i  to  4  per  cent,  solution 
of  /3-eucaine  in  normal  saline  solution  containing  i  part  in  10,000  of 


INFLAMMATION  AND  ITS  SEQUELS 


adrenalin  is  employed.  For  details  of  the  method  of  producing  local 
anaesthesia  see  Appendix. 

Application  of  Grafts. — When  a  sufficient  number  of  grafts  has  been 
cut,  the  bandage,  sponges,  and  protective  are  removed  from  the  raw 
surface  of  the  ulcer  and  the  grafts  are  applied  to  it  if  the  bleeding  has 
stopped,  as  is  generally  the  case.  The  raw  surface  usually  has  a  thin  layer 
of  blood-clot  upon  it,  and  this  should  be  wiped  away.  Each  graft 
is  lifted  with  forceps  or  the  fingers,  and  applied  with  the  cut 
surface  downwards,  and  then  the  graft  is  carefully  unfolded  by  means 
of  two  probes  and  stretched  evenly  over  the  surface  (see  Fig.  19). 

The  grafts  should  overlap  the 
edges  of  the  skin  and  also  each 
other,  so  that  no  part  of  the  raw 
surface  is  left  exposed,  for  granu- 
lations always  spring  up  on  the 
uncovered  parts,  and  are  apt  to 
destroy  the  grafts  in  their  vicinity ; 
moreover,  a  thin  scar  is  left  at 
these  points  which  may  break 
down  subsequently.  The  graft 
is  always  thinner  at  its  edge  than 
at  its  centre,  and  it  is  these  thin 
edges  which  overlap  each  other 
or  the  edge  of  the  skin  ;  there  is 
no  real  sloughing  of  these  over- 
lapping edges. 

Dressing  the  Grafts.  —  Air- 
bubbles  and  blood-clot  collect 
beneath  the  grafts  during  their 
application,  and  must  be  got  rid 
of  by  pressure  so  applied  as  not 
to  detach  the  grafts ;  unless  this 

be  done,  the  grafts  may  fail  to  adhere.  The  following  is  a  good  plan : 
strips  of  sterilised  protective  (see  p.  51)  about  an  inch  broad  and  long 
enough  to  overlap  the  wound  are  applied  to  the  grafted  surface  from 
below  upwards,  each  strip  overlapping  the  one  below,  and  extending  well 
on  to  the  skin  at  each  end  (see  Fig.  20).  If  each  strip  be  grasped  by 
its  two  ends  and  pressed  down  firmly  on  the  limb  as  it  is  put  on,  the 
pressure  suffices  to  expel  the  air-bubbles  and  blood,  and  also  to  arrest 
further  capillary  oozing.  Another  plan,  which  is  even  more  efficacious 
after  a  little  practice,  is  to  lay  a  fine  soft  flat  sponge  over  the  grafts 
and  then  press  it  down  firmly,  taking  care  to  avoid  any  lateral  move- 
ment which  would  dislodge  the  grafts.  When  the  sponge  is  lifted  the 
grafts  will  be  found  to  adhere  firmly. 

Various  dressings  may  be  used.     When  protective  has  been  applied  as 


FIG.  19. — THIERSCH'S  METHOD  OF  SKIN-GRAFT- 
ING. The  graft  applied.  The  skin-grafts  over- 
lap the  margins  of  the  ulcer  and  one  another. 


ULCERATION 


57 


described  above,  cyanide  gauze  wrung  out  of  i  in  4000  sublimate  solution 
is  applied,  with  salicylic  wool  outside  it.  When  the  grafts  have  been 
made  to  adhere  by  sponge  pressure,  a  very  useful  dressing  is  plain  gauze 
sterilised  by  boiling  and  then  smeared  with  vaseline  sterilised  by  heat. 
The  limb  should  be  placed  upon  a  splint,  or  so  fixed  that  movement 
cannot  occur. 

Some  surgeons  prefer  perforated  silver  foil  to  the  protective.  There 
is  no  need  to  cut  this  in  strips  as  the  perforations  allow  discharges  to 
escape  ;  it  has  also  the  advantage  of  being  readily  sterilised  by  boiling, 
but  is  not  quite  so  pliable  as  the  protective  is.  Thin  sheet-rubber, 
which  can  be  perforated  with 

holes  if  desired,  is  also  used.  • 

An  excellent  protective  tissue,  -  /  • 

apparently  composed  of  eel-  • — .\ .     ' 

lulose,  has  been  introduced 
recently.  This  has  the  ad- 
vantage that  it  can  be 
boiled  without  deterioration, 
and,  as  it  is  transparent,  the 
grafts  can  be  inspected  with- 
out disturbance. 

The  place  from  which  the 
grafts  have  been  taken  may 
be  dressed  with  dilute  boric 
ointment,  which  need  not  be 
disturbed  for  ten  days.  At 
the  end  of  that  time  the 


/     \ 


FIG.  20. — THIERSCH'S  METHOD  OF  SKIN-GRAFTING. 
Applying  the  protective.  The  grafts  (indicated  by  the 
dotted  line)  are  covered  with  overlapping  strips  of 
protective  tissue. 


whole  surface  will  usually  be 
healed,  unless  the  razor  has 
somewhere  gone  deeper  than 
is  necessary.  If  healing  be 
not  quite  complete,  the  boric 
ointment  may  be  re-applied. 
Changing  the  First  Dress- 
ing.— The  dressing  should  be  left  on  the  grafted  surface  for  about  five 
days ;  in  some  cases  it  may  even  be  left  for  a  week.  If  the  wound  be 
aseptic,  no  suppuration  or  decomposition  takes  place  beneath  it.  Before 
being  removed,  the  dressing  should  be  thoroughly  soaked  with  a  I  in 
2000  sublimate  solution,  for  the  protective  or  the  dressing  may  stick  at 
the  edge  and  adhere  to  a  graft,  which  may  thus  be  peeled  off  unless 
great  care  be  taken.  The  parts  should  be  gently  cleansed  with  the 
same  solution,  and  a  dressing  similar  to  that  put  on  originally  should  be 
employed  for  about  another  week.  At  the  end  of  that  time  the  grafts 
are  fairly  firmly  adherent,  and  then  the  half-strength  boric  ointment  is 
the  best  application. 


58  INFLAMMATION  AND   ITS  SEQUELAE 

After-treatment. — It  will  be  found  that,  even  at  the  first  dressing,  the 
grafts  present  a  pink  colour  and  are  adherent  to  the  deeper  surface, 
though  they  are  still  readily  detachable.  In  the  course  of  about  a  week 
the  old  cuticle  peels  off,  but  no  raw  surface  is  left.  Later  on,  there  is 
a  great  tendency  to  the  formation  of  new  epithelium,  cornification,  and 
drying-up,  and  it  is  in  avoiding  the  latter  condition  that  ointments  are 
so  useful.  In  fact,  till  the  scar  is  absolutely  sound,  it  is  well  to  keep  the 
surface  covered  with  some  greasy  application,  the  best  being  the  half- 
strength  boric  ointment.  For  many  months  the  grafted  surface  is  likely 
to  scale  or  crack  and  this  might  prove  a  starting-point  for  the  occurrence 
of  sepsis  which  would  cause  the  newly  grafted  area  to  slough.  It  is 
important  to  keep  the  scar  as  supple  as  possible,  and  therefore  it  should 
be  constantly  anointed  with  cold-cream,  vaseline,  or  lanoline.  Grafted 
surfaces  upon  the  face,  however,  do  not  betray  this  tendency  for  any 
length  of  time. 

Time  required  for  Cure. — It  is  important  to  know  when  the  patient 
may  be  allowed  to  walk  about  after  an  ulcer  of  the  leg  has  been  skin- 
grafted.  If  he  begins  too  soon,  the  grafts  will  almost  certainly  become 
detached.  That  this  will  be  so,  is  evident  from  a  consideration  of  the 
mode  by  which  the  adhesion  of  the  grafts  takes  place.  At  first  they  adhere 
to  the  surface  of  the  sore  simply  by  means  of  the  effused  and  coagulated 
lymph.  Cells  rapidly  spread  into  this  lymph,  and  in  the  course  of  two 
or  three  days,  the  space  between  the  graft  and  the  raw  surface  is  occupied 
by  a  mass  of  young  cells.  In  this  tissue  young  blood-vessels  develop 
and  penetrate  into  the  grafts,  whilst,  at  the  same  time,  the  cells  of  the 
grafts  grow  and  assist  in  the  development  of  the  young  tissue  and  of 
the  blood-vessels.  Thus  the  graft  becomes  vascularised ;  but  for  a  con- 
siderable time  the  tissue  between  it  and  the  surface  of  the  sore  contains 
many  young  blood-vessels  with  delicate  walls,  and  therefore,  if  the 
patient  stands  erect  and  allows  the  pressure  of  the  column  of  blood  to 
tell  on  these  vessels,  they  rupture,  and  bleeding  occurs  beneath  the 
graft  and  leads  to  its  detachment.  It  requires  a  long  time  before  the 
graft  is  firmly  incorporated  with  the  tissue  beneath  by  the  development 
of  elastic  fibres  ;  indeed,  it  may  be  reckoned  that  this  union  is  not  com- 
plete until  from  three  to  six  months  have  elapsed.  The  graft  will  in  all 
probability  be  destroyed  if  the  patient  walks  about  within  three  months 
of  the  grafting.  Hence,  unless  that  time  can  be  devoted  to  the  treat- 
ment, it  is  not  worth  while  employing  skin-grafting  for  ulcers  of  the 
lower  limbs.  By  this,  however,  it  is  not  implied  that  it  is  necessary  to 
keep  the  patient  in  bed  for  the  whole  time,  but  merely  that  the  foot 
must  not  be  allowed  to  hang  down,  nor  must  any  weight  be  borne  upon 
it.  At  the  end  of  about  six  weeks  the  patient  may  be  allowed  to  get  up 
and  lie  on  a  sofa  or  sit  with  the  leg  on  another  chair,  but  the  limb  must 
not  be  permitted  to  hang  down.  At  the  end  of  about  three  months  he 
may  be  allowed  to  get  about,  but  in  order  to  prevent  the  detachment  of 


ULCERATION  59 

the  grafts,  he  should  be  fitted  with  a  knee-rest  and  peg  on  which  he 
walks,  the  leg  projecting  out  behind  him.  If  possible  he  should  not  put 
his  foot  to  the  ground  until  six  months  have  elapsed. 

In  cases  of  sores  on  other  parts  of  the  body,  where  the  erect  posture 
does  not  cause  congestion  of  the  part,  the  patient  may  be  allowed  to 
walk  about  after  the  first  three  weeks. 

Results. — The  scar  which  results  after  skin-grafting  performed  in  this 
manner  is  of  a  satisfactory  character,  and  ulcers  which  have  been  in- 
tractable for  years  may  be  closed  satisfactorily  by  its  means.  In  order 
to  obtain  anything  in  the  nature  of  a  permanent  cure,  however,  the 
prescribed  period  of  rest  must  be  adhered  to  rigidly. 

Treatment  when  a  Patient  cannot  lie  up. — The  surgeon  has  also 
to  treat  ulcers  in  the  out-patient  department  of  hospitals,  where  the 
measures  above  referred  to  cannot  be  employed,  as  the  patient  is  unable 
to  afford  the  necessary  time,  and  the  question  then  arises,  What  is  best 
to  be  done  ?  In  the  first  place,  one  cannot  expect  to  cure  the  ulcer,  though 
in  some  rare  cases  the  ulcer  does  actually  heal ;  in  the  majority,  however, 
it  remains  open,  even  though  it  may  be  somewhat  improved.  Never- 
theless, a  good  deal  may  be  done  to  alleviate  the  patient's  troubles  and 
prevent  the  further  spread  of  the  sore.  In  treating  out-patients  it  is 
impossible  to  get  rid  of  the  dependent  position  of  the  limb  and  the  bad 
results  this  produces,  but  these  may  be  mitigated  by  giving  as  much 
support  to  the  circulation  as  possible  ;  the  septic  condition  of  the  wound 
may  also  be  got  rid  of. 

These,  then,  are  the  two  points  to  be  aimed  at  in  the  '  ambulatory  ' 
treatment  of  ulcers  of  the  leg — support  of  the  circulation  and  asepsis 
of  the  sore.  The  asepsis  of  the  sore  is  effected  by  the  means  already 
described  (see  p.  49).  The  most  popular  method  of  supporting  the 
circulation  is  by  the  use  of  Martin's  rubber  bandage  (see  p.  48) ;  it  should 
be  applied  in  the  morning  before  the  patient  gets  out  of  bed,  and 
should  be  put  on  loosely,  being  simply  rolled  spirally  around  the 
limb.  The  rubber  should  not  be  stretched  when  applied,  for  one  cannot 
gauge  the  amount  of  pressure  exerted,  and  as  the  limb  swells  when  the 
patient  commences  to  walk  about,  the  bandage  may  become  unbearably 
tight.  If  put  on  loosely,  the  oedema  which  occurs  on  walking,  distends 
the  bandage  and  puts  it  on  the  stretch,  and  in  the  course  of  an  hour  or 
two  it  provides  a  fairly  satisfactory  amount  of  support.  When  the  patient 
goes  to  bed,  the  bandage  should  be  removed,  washed,  and  hung  up  to  dry  ; 
it  is  a  mistake  to  wear  it  during  the  night.  When  first  introduced,  the 
rubber  bandage  was  applied  direct  to  the  surface  of  the  sore  without  any 
dressing,  but,  if  this  be  done,  the  discharge  decomposes  beneath  the 
bandage  and  prevents  healing.  Hence  the  ulcer  should  be  disinfected 
and  then  a  suitable  dressing — to  be  mentioned  immediately — should  be 
applied  beneath  the  bandage.  The  dressing  must  not  be  of  a  greasy 
nature  as  otherwise  the  rubber  will  be  spoilt. 


60  INFLAMMATION  AND  ITS  SEQUELS 

We  consider,  however,  that  the  method  known  as  Unna's  bandage  is 
superior  to  Martin's  and  we  advise  its  adoption   in  the  first  instance 
at  any  rate.     This  is  a  bandage  stiffened  with  gelatine,  and  its   ad- 
vantages are  that  the  patient  cannot  meddle  with  the  sore,  and  that 
it  gives  a  uniform  elastic  support  without  unnecessary  pressure.     It 
can  be  applied  in  various  ways,  but  the  method  we  prefer  is  as  follows. 
In  the  first  place,  the  sore  and  the  skin  around  are  thoroughly  disin- 
fected, and  a  dressing  of  protective  and  boric  lint  is  applied  ;   later  on, 
half-strength  boric,  or  eucalyptus  or  any  other  suitable  antiseptic  oint- 
ment may  be  substituted.     After  the  sore  has  been  properly  purified,  a 
mixture  consisting  of  40  parts  of  water,  40  of  glycerine  and  10  of  gelatine, 
with  some  oxide  of  zinc  to  make  it  stiffer,  is  applied  to  the  outside  of  the 
dressing.     This  mixture  becomes  solid  at  the  ordinary  temperature,  but 
is  readily  liquefied  by  gentle  heat.i      The  liquefied  material  is  painted 
over  the  outside  of  the  dressing,  and  a  double-headed  bandage  is  put  on, 
beginning  over  the  centre  of  the  ulcer,  one  roll  going  downwards  towards 
the  toes  and  the  other  upwards  towards  the  knee.     This  bandage  is 
applied  smoothly  and  not  tightly,  the  melted  mixture  is  then  painted 
on  it,  and,  before  it  sets,  another  bandage  dipped  in  hot  water  is  applied 
over  it.     This  dries  in  a  very  short  time  and  forms  a  firm,  elastic,  and 
at  the  same  time  not  too  heavy  support  to  the  limb,  and  thus  some  of  the 
disadvantages  of  other  dressings,  more  especially  the  irregularity  of  the 
pressure  which  often  occurs  in  a  Martin's  bandage,  are  avoided.     If  pos- 
sible, Unna's  bandage  should  be  put  on  early  in  the  day  before  the  leg 
has   swollen   from   walking   about.     The   dressing  should   be   changed 
according  to  the  amount  of  discharge  present ;   usually  at  first  every 
other  day,  but  at  less  frequent  intervals  as  the  discharge  diminishes. 
It  is  readily  removed  by  putting  the  leg  in  a  tub  of  warm  water  so  as  to 
melt  the  gelatine;    the  bandages  can  then  be  unwound  easily.     When 
the  ulcer  has  healed,  the  parts  should  be  supported  for  some  time  by 
Unna's  bandage  ;    massage  should  also  be  used,  more  especially  if  the 
scar  be  hard  and  fixed  and  the  muscles  atrophied.     The  legs  should  be 
frequently  immersed  in  a  warm  bath,  and  lanoline  should  be  rubbed  into 
the  skin  to  soften  the  epidermis. 

SPECIAL  POINTS  IN  THE  TREATMENT  OF  THE  VARIOUS 
FORMS  OF  ULCER. 

The  foregoing  remarks  as  to  treatment  apply  to  all  ulcers,  but  it  will 
now  be  well  to  mention  certain  points  peculiar  to  the  treatment  of  the 
individual  forms. 

1  This  is  best  done  in  a  large  glue-pot,  or  a  gallipot  stood  in  a  saucepan  of 
boiling  water ;  in  the  latter  case  a  piece  of  wood  should  be  placed  beneath  the 
gallipot  in  order  to  prevent  it  from  cracking.  A  very  useful  formula  when  there 
is  any  dermatitis  is :  Gelatine  30  parts,  oxide  of  zinc  30  parts,  glycerine  50  parts, 
water  90  parts.  Melt,  and  add  ichthyol  6  parts. 


ULCERATION  61 

Simple  Ulcer. — The  simple  ulcer  is  one  that  is  prevented  from  healing 
by  various  local  causes  not  usually  of  a  serious  character.  The  chief  of 
these  are  standing  and  walking,  especially  if  varicose  veins  be  present  or 
the  patient  be  advanced  in  years.  If  these  causes  be  removed,  and  the 
limb  be  placed  at  rest  in  a  suitable  position,  the  sore  will  heal  rapidly.  In 
the  treatment  of  a  simple  ulcer,  then,  the  patient  should  be  put  to  bed, 
the  leg  elevated  on  a  pillow,  fixed  if  necessary,  and  suitable  dressings 
applied  to  the  part.  It  is  well  to  disinfect  the  surface  of  the  ulcer  (see 
p.  49),  but  when  the  surface  is  comparatively  healthy  it  is  hardly  neces- 
sary to  destroy  the  granulations  with  pure  carbolic  acid ;  washing 
them  with  I  in  2000  sublimate  solution  will  suffice.  The  best  dressing 
is  the  half-strength  boric  ointment,  used  as  described  on  p.  51,  and 
changed  either  daily  or  every  alternate  day.  When  the  ulcer  is  large, 
especially  if  the  patient  be  old,  skin-grafting  (see  p.  53)  should  be 
employed. 

Inflamed  Ulcer. — Here  there  is  not  only  ulceration  but  also  acute  in- 
flammation, and  both  conditions  require  treatment.  The  patient  should 
be  put  to  bed  with  the  leg  elevated,  and  warm  antiseptic  fomentations 
applied.  The  best  of  these  is  boric  lint  dipped  in  warm  I  in  4000  sublimate 
solution  or  boric  lotion,  applied  wet  over  the  ulcer  and  the  skin  in  the 
vicinity,  and  overlapped  in  all  directions  by  guttapercha  tissue  or  mack- 
intosh. This  dressing  should  be  changed  twice  a  day  at  least,  and  oftener 
if  the  inflammation  be  severe  or  the  pain  acute.  Before  doing  this,  it  is 
well  to  disinfect  the  surface  of  the  sore  by  the  application  of  undiluted 
carbolic  acid.  Another  important  point  is  local  depletion.  When  these 
ulcers  are  multiple  they  are  often  separated  by  bridges  of  skin  which 
are  much  swollen  and  inflamed  and  are  prone  to  become  gangrenous. 
Division  of  these  bridges  will  often  prevent  the  impending  gangrene  and 
the  consequent  loss  of  tissue,  while  at  the  same  time  it  allows  the  escape 
of  exudation  and  of  blood,  and  so  improves  the  inflammatory  condition. 
Even  when  these  bridges  of  skin  are  not  present,  considerable  improvement 
will  be  obtained  by  making  incisions  into  the  inflamed  tissues  around, 
the  cuts  radiating  from  the  centre  of  the  ulcer.  When  the  inflammation 
has  subsided,  the  treatment  is  that  of  a  healing  sore.  Skin-grafting  (see 
p.  53)  will  be  called  for  when  the  ulcer  is  large. 

Weak  Ulcer. — In  a  weak  ulcer  the  cause  of  the  weakness  (see  p.  43) 
must  be  sought  for  and  removed  if  possible.  If  general  anaemia  be  the 
cause,  iron  should  be  administered ;  an  excellent  way  to  give  it  is  in  the 
form  of  Blaud's  capsules,  commencing  with  doses  of  five  grains  three 
times  a  day.  Some  of  the  graver  forms  of  anaemia,  however,  yield  more 
quickly  and  satisfactorily  to  arsenic,  and  therefore  these  drugs  may  be 
given  in  combination,  or,  if  the  iron  does  not  seem  to  suit,  liquor  arseni- 
calis  should  be  substituted  for  it,  beginning  with  doses  of  three  minims 
after  food  twice  a  day,  and  increasing  the  dose  by  one  minim  every  third 
or  fourth  day  up  to  twelve  minims  or  more.  The  medicinal  treatment 


62  INFLAMMATION  AND   ITS  SEQUELS 

must  be  accompanied  by  nourishing  diet  and  good  hygienic  conditions. 
When  the  weakness  of  the  ulcer  is  due  to  oedema  from  heart  or  kidney 
disease,  treatment  suitable  to  these  affections  must  be  employed. 

Among  the  local  conditions  the  first  that  should  be  looked  for  is 
difficulty  in  the  contraction  of  the  sore.  This  may  result  from  adhesion 
to  the  deeper  parts,  from  the  hardness  of  the  tissues  around  the  sore,  as  in 
the  callous  ulcer,  or  from  the  size  of  the  original  sore  and  the  large  amount 
of  cicatricial  tissue  formed  during  healing,  etc.  If  it  be  due  simply  to 
the  denseness  of  the  scar,  apart  from  exudation  into  the  tissues,  lateral 
incisions  through  the  sound  parts  beyond  will  sometimes  allow  the  ulcer 
to  heal.  When  the  latter  is  adherent  to  bone  it  should  be  detached, 
portions  of  the  thickened  margin  cut  away,  the  surface  scraped  with  a 
sharp  spoon,  and  skin-grafting  employed.  In  some  instances  portions 
of  bone  have  been  removed,  or  joints  have  been  excised  to  allow  of  con- 
traction taking  place ;  but  this  can  very  rarely  be  necessary,  especially 
since  the  introduction  of  Thiersch's  method  of  skin-grafting.  In  every 
case  of  weak  ulcer  the  part  must  be  kept  at  rest  in  the  elevated  position, 
and  the  weak  granulations  should  be  destroyed  by  scraping  them  away 
and  applying  undiluted  carbolic  acid  to  the  raw  surface  ;  the  ulcer  is  thus 
disinfected  at  the  same  time. 

When  the  granulations  become  exuberant  in  an  ulcer  which  has  been 
rendered  aseptic,  they  should  be  rubbed  over  freely  with  a  pencil  of  solid 
nitrate  of  silver,  the  surface  of  the  sore  being  dried  before  the  caustic  is 
applied.  Should  there  be  excessive  growth  of  the  granulations  after- 
wards, they  may  be  kept  down  by  repeated  applications  of  solid  nitrate  of 
silver  or  sulphate  of  copper  made  daily,  or  every  other  day.  The  caustic 
must  not  be  applied  to  the  healing  edge. 

Various  stimulant  applications  are  usually  advised  for  weak  ulcers, 
such  as  solutions  of  sulphate  of  zinc  (the  so-called  red  lotion),1  or  sulphate 
of  copper  in  a  strength  of  two  grains  to  the  ounce  of  water.  These  are 
chiefly  of  use  in  that  form  of  weak  ulcer  in  which  the  surface  is  inactive 
and  shows  few  and  imperfect  granulations.  They  are  useless  in  the  cases 
with  exuberant  or  cedematous  granulations.  It  is  doubtful  how  far 
benefit  results  from  these  applications,  and  they  should  only  be  used  in 
the  particular  form  of  weak  ulcer  to  which  we  have  alluded,  and  which 
is  most  often  associated  with  general  anaemia.  When  the  sore  is  cedema- 
tous, the  best  dressing  is  weak  boric  ointment ;  the  protective  and  boric 
lint  dressing  tends  to  foster  cedema  of  the  granulations  by  confining  the 
moisture.  As  soon  as  any  of  these  ulcers  get  into  a  healthy  condition, 
skin-grafting  should  be  employed. 

Irritable  Ulcer. — The  intense  pain  associated  with  this  form  of  ulcer 
is  best  met  by  cauterising  the  ulcer  thoroughly  with  solid  nitrate  of  silver, 
so  as  to  destroy  completely  the  sensitive  terminations  of  the  nerve. 

1  The  formula  for  '  red  lotion '  is  as  follows :  R  acidi  borici,  gr.  x ;  zinci  sulphatis 
gr.  j  ;  spiritus  rosmarini;  spiritus  lavandulae  co.,  aa  IT^ix;  aquam  ad  §j. 


ULCERATION  63 

Treatment  on  the  principles  recommended  for  a  simple  ulcer  should  be 
carried  out  subsequently.  When  these  ulcers  are  quite  small,  however, 
complete  excision  with  immediate  skin-grafting  is  the  best  treatment. 

Phagedenic  Ulcer. — This  ulcer  requires  energetic  treatment  in  order  to 
destroy  the  infected  tissues.  In  order  to  do  this,  the  slough  should  be 
scraped  away  with  a  sharp  spoon  or  clipped  off  with  scissors,  and  then 
the  actual  cautery  (see  p.  20),  potassa  fusa  (see  p.  21),  or  nitric  acid  should 
be  applied  to  the  surface  of  the  sore ;  of  these  the  actual  cautery  is  the 
best.  It  should  be  heated  to  white  heat,  and  the  parts  thoroughly 
destroyed  by  it ;  Paquelin's  cautery  will  also  answer  the  purpose.  It  is 
possible  to  gauge  the  amount  of  destruction  done  by  means  of  the  cautery, 
whereas  caustic  potash  generally  destroys  more  of  the  tissue  than  is  really 
necessary,  and  the  action  of  nitric  acid  is  interfered  with  by  the  coagulation 
of  the  albumen  that  it  causes,  so  that,  as  a  rule,  it  does  not  extend 
sufficiently  deeply.  After  the  application  of  the  cautery,  undiluted  car- 
bolic acid  should  be  sponged  over  the  surface,  and  a  dressing  of  strong 
carbolic  oil  (i  to  5)  should  be  applied  (see  p.  50).  When  nitric  acid  is 
used,  its  action  should  be  neutralised,  after  the  lapse  of  a  few  minutes, 
by  pouring  a  strong  solution  of  ordinary  washing-soda  on  the  wound ;  this 
should  be  done  until  effervescence,  from  the  liberation  of  carbonic  acid 
gas,  ceases.  In  these  ulcers  the  first  object  is  not  to  obtain  healing,  but 
to  eradicate  a  dangerous  bacterial  poison  which  spreads  with  great 
rapidity. 

Varicose  Ulcer. — This  ulcer  must  be  treated  by  rest  in  the  elevated 
position,  disinfection  of  the  sore,  the  application  of  protective  and  boric 
lint  dressing,  or  boric  ointment,  and  subsequent  skin-grafting.  But  the 
patient  should  not  be  allowed  to  go  about  again  till  the  varicose  veins 
themselves  have  been  treated.  As  long  as  the  limb  is  elevated,  the  presence 
of  varicose  veins  does  not  delay  the  healing,  but  directly  the  patient 
begins  to  walk  about  they  favour  the  subsequent  breaking  down  of  the 
ulcer  in  a  very  marked  degree.  As,  however,  under  proper  conditions,  the 
varicose  veins  do  not  interfere  with  the  healing  of  the  wound,  it  is  well  to 
defer  the  operation  until  the  ulcer  has  closed,  so  as  to  avoid  any  risk  of 
sepsis  in  connection  with  the  operation  on  the  veins.  The  treatment 
of  varicose  veins  is  referred  to  in  detail  in  Vol.  II. 

Callous  Ulcer. — Here  the  obstacle  to  healing  is  the  callous  condition 
of  the  surrounding  parts,  and  the  surgeon's  first  efforts  must  be  directed 
to  getting  rid  of  this.  If  the  limb  be  put  at  rest,  the  leg  elevated, 
and  the  sore  rendered-  aseptic,  this  callous  condition  will  subside  com- 
paratively quickly,  and  in  the  course  of  two  or  three  weeks  the  sore  will 
present  a  healthy  appearance  and  the  healing  process  will  begin.  When 
it  is  desirable  to  expedite  matters,  or  when  the  thickening  of  the  tissues 
does  not  disappear  as  quickly  as  usual,  some  of  the  other  plans,  which 
have  been  referred  to  on  p.  18,  may  be  employed  ;  of  these  the  best  is 
the  application  of  a  blister,  provided  that  the  kidneys  be  healthy.  After 


64  INFLAMMATION  AND  ITS  SEQUELS 

the  callous  edges  of  the  ulcer  have  been  got  rid  of,  and  the  sore  has  assumed 
a  healthy  condition,  skin-grafting  should  be  employed  (see  p.  52) ;  when 
varicose  veins  are  present,  they  should  be  operated  on  after  the  wound 
has  healed,  but  before  the  patient  is  allowed  to  walk  about.  For  the 
'  ambulatory  '  treatment  of  callous  ulcer,  see  p.  59. 

Pressure  Ulcer. — A  pressure  ulcer  occurring  in  the  centre  of  a  callosity 
is  sometimes  very  obstinate  in  healing,  and  the  best  treatment  is  to  cut 
away  the  callosity  which  surrounds  the  ulcer,  and  to  scrape  and  disinfect 
the  surface  of  the  latter.  In  this  way  a  shallow  healthy  sore  is  left,  which 
heals  comparatively  quickly  if  the  limb  be  elevated  and  kept  at  rest  in 
the  usual  manner.  When  a  pressure  ulcer  occurs  in  the  foot,  it  is  perhaps 
well  to  excise  and  skin-graft  it,  in  order  to  avoid  the  thin  scar  which 
results  from  the  natural  process  of  healing,  and  which  is  very  apt  to 
remain  tender  or  break  down  subsequently;  and  when  the  patient  first 
begins  to  walk  about,  the  boot  should  be  excavated  at  the  part  corre- 
sponding to  the  scar,  so  that  pressure  does  not  tell — for  a  time,  at  any 
rate — on  the  site  of  the  ulcer. 

Paralytic  Ulcer. — It  is  often  very  difficult  to  obtain  healing,  and  stimu- 
lating applications  should  be  employed.      In  the  early  stage  cyanide 
gauze  should  be  applied  directly  to  the  raw  surface,  after  the  ulcer  has 
been  disinfected,  and  is  very  useful  as  a  means  of  inducing  granulation. 
After  granulation  has  occurred,  the  best  dressing  is  perhaps  boric  lint 
soaked  in  balsam  of  Peru.     This  dressing  is  antiseptic,  and  possesses  a 
markedly  stimulating  action;  it  should  be  changed  daily.     When  the 
healing  is  well  in  progress,  the  half -strength  boric  ointment  (see  p.  51) 
should  be  substituted.     The  position  of  the  limb,  rest,  the  administration 
of  nourishing  diet,  etc.,  must  of  course  be  attended  to.     Besides  this,  the 
application  of  spirits  of  wine  to  the  parts  around,  and  the  use  of  massage 
(see  p.  23)  and  electricity  to  the  whole  limb,  should  be  had  recourse  to, 
with  the  view  of  improving  the  nutrition  and  increasing  the  circulation. 
The  electric  current  may  be  employed  in  one  of  two  ways.    The  simplest 
plan  consists  in  covering  the  whole  of  the  ulcerated  area  with  a  layer  of 
gauze  or  absorbent  wool,  thoroughly  wetted  with  salt  solution,  and  apply- 
ing to  this  the  negative  pole  of  a  galvanic  battery,  the  positive  pole  being 
applied  to  the  spinal  column.     A  current  of  about  five  milliamperes  should 
be  used  at  first ;  if  this  cause  pain  it  must  be  diminished.     The  apparatus 
should  be  so  arranged  that  the  circuit  can  be  opened  and  closed  about 
thirty  times  per  minute.     The  sittings  should  occupy  from  ten  to  fifteen 
minutes  and  may  be  made  daily.     The  strength  of  the  current  may  be 
cautiously  increased  up  to  ten  or  more  milliamperes,  but  it  should  never  be 
strong  enough  to  cause  pain.     The  other  method  is  to  immerse  the  affected 
limb  in  a  small  electrical  bath.     This  may  be  improvised  by  using  a  china 
basin  or  wooden  tub  or  trough  of  suitable  size,  which  is  filled  with  salt 
solution  and  in  which  the  affected  part  in  immersed.     The  electrodes, 
which  should  be  in  the  form  of  flat  copper  plates  connected  with  the  poles 


ULCERATION 


of  a  battery,  are  placed  on  either  side  of  the  limb,  the  negative  being  in 
direct  contact  with  the  ulcer.  A  current  sufficiently  weak  for  the  patient 
to  bear  without  discomfort  must  be  employed.  This  method  is  more 
cumbrous  than  the  other  and  offers  no  advantages  over  it. 

Perforating  ulcers  of  the  foot  are  often  obstinate  under  treatment. 
The  limb  may  be  placed  at  rest  on  a  splint  in  the  elevated  position  for 
a  long  time  without  the  slightest  attempt  at  healing  occurring.  One 
reason  for  this  no  doubt  is  the  tendency  of  the  epithelium  to  fill  up  the 
cavity  and  decompose  there,  or  else  to  spread  down  the  edges  of  the 
ulcer.  The  most  satisfactory  plan  in 
these  cases  is  to  excise  the  edges  and  sides 
of  the  ulcer,  cut  away  the  whole  of  the 
callosity  around,  scrape  out  the  bottom 
of  the  ulcer  until  sound  tissue  is  reached 
and  then  disinfect  the  whole  surface  with 
undiluted  carbolic  acid  (see  p.  50),  and 
dress  it  antiseptically. 

Healing  will  not  begin  until  the  cavity 
of  the  ulcer  has  filled  up  with  granula- 
tions, and  therefore  it  is  well  to  promote 
granulation  by  stuffing  the  cavity  lightly 
with  cyanide  gauze  which  greatly  favours 
this  by  its  irritation.  The  gauze  should 
be  changed  daily,  but  the  packing  should 
be  left  out  as  soon  as  granulation  has 
occurred.  When  the  granulations  have 


FIG.  21. — EXCISION  OF  A  PERFORA- 
TING ULCER  OF  THE  FOOT. — Dorsum 
of  the  foot  showing  the  opening  of  a 
perforating  ulcer  between  the  first  and 
second  toes.  The  broken  line  shows 
the  incision  round  the  margin  of  the 
ulcer  continued  up  into  the  cleft 
between  the  toes. 


grown  up  nearly  to  the  level  of  the  sur- 
rounding surface,  some  non-irritating 
dressing,  such  as  the  half-strength  boric 
ointment  (see  p.  51),  may  be  substituted 
for  it.  When  the  ulcer  is  extensive,  skin- 
grafting  maybe  employed  with  advantage. 

When  the  ulcer  is  situated  between  the  great  and  the  next  toe  it  can 
often  be  excised  conveniently.  An  incision  is  made  around  the  opening 
of  the  ulcer  extending  forward  into  the  cleft  between  the  toes  (see 
Fig.  21).  A  similar  incision  is  then  made  upon  the  plantar  surface 
of  the  foot  extending  forwards  to  meet  the  first  incision  between 
the  toes.  As  the  incisions  are  deepened  the  space  between  the  first 
and  second  metatarsals  becomes  opened  up,  a  free  exposure  of  the 
walls  of  the  perforating  ulcer  can  be  made  and  any  sloughs  or  dead 
bone  removed.  After  the  operation  the  parts  fall  into  position  and 
the  wound  generally  heals  well  by  granulation. 

Diabetic  Ulcer. — In  these  cases  the  local  treatment  must  be  carried 
out  on  the  same  principles — namely,  disinfection,  position,  and  careful 
dressing.  Of  dressings,  boric  fomentations  are  the  best  at  first ;  but 


66  INFLAMMATION  AND   ITS  SEQUELS 

these  ulcers  will  not  do  well  unless  something  be  done  to  improve  the 
constitutional  condition.  In  the  case  of  diabetes,  the  patient  must 
be  put  upon  an  anti-diabetic  diet  and  codeine  (see  p.  80).  Operations 
are  not  satisfactory  in  a  diabetic  patient,  and  this  is  the  one  form 
of  ulcer  in  which  skin-grafting  cannot  be  recommended.  If  the 
ulcer  be  extensive  and  tend  to  become  gangrenous,  the  case  should 
be  treated  as  one  of  diabetic  gangrene.  In  less  severe  cases  the  ulcer 
should  be  allowed  to  heal  if  it  will,  and  Unna's  bandage  should  be 
employed  afterwards,  with  the  object  of  preventing  a  recurrence. 


CHAPTER  IV. 

GANGRENE. 

DEFINITION. — By  gangrene  is  meant  death  of  macroscopic 
portions  of  the  tissues,  and  the  term  is  usually  employed  only  when  the 
portion  which  dies  is  extensive,  more  especially  when  the  whole  or  part 
of  an  extremity  is  affected.  If  the  portion  of  gangrenous  tissue  be  small, 
the  dead  part  is  termed  a  slough,  and  the  process  is  spoken  of  as  sloughing. 

CLASSIFICATION. — In  speaking  of  gangrene  two  classifications 
are  employed — the  one  a  clinical  classification  into  dry  and  moist 
gangrene,  the  other  an  etiological  one  into  direct,  indirect,  and  specific 
gangrene.  The  use  of  the  latter  classification  makes  the  whole  subject  of 
treatment  more  intelligible. 

SYMPTOMS. — It  will  save  repetition  if  we  speak  first  of  the  terms 
dry  and  moist  gangrene.  Dry  Gangrene  is  the  form  in  which  the 
gangrene  occurs  so  slowly  that  the  fluids  of  the  part  have  time  to  dry  up. 
Under  these  circumstances  the  dead  tissues  do  not  form  proper  pabulum 
for  the  ordinary  putrefactive  bacteria,  and  therefore  the  usual  signs  of 
putrefaction  are  wanting.  The  part  usually  has  a  mouldy  rather  than 
a  foul  odour,  and  there  is  not  the  same  amount  of  septic  absorption  as 
in  the  moist  form.  The  patient  is  at  first  comparatively  or  altogether 
free  from  fever  and  symptoms  of  septic  poisoning,  and  there  is  less 
inflammation  in  the  neighbourhood  of  the  dead  part  than  is  the  case  in 
the  moist  variety.  The  gangrenous  part  is  black,  shrivelled  up,  greasy, 
and  semi-transparent  from  the  breaking  down  of  the  fat,  so  that  the 
tendons  and  bones  can  be  seen  through  the  skin.  At  the  junction  of 
the  dead  with  the  living  part  there  is  a  faint  red  blush.  In  dry  gangrene, 
as  a  rule,  the  line  of  demarcation  is  not  permanent,  and  after  a  time 
fresh  gangrene  may  appear  above  it.  The  chief  symptom  is  pain. 

Moist  Gangrene,  on  the  other  hand,  is  characterised  by  rapid 
putrefaction  of  the  dead  part,  and  the  patient  soon  shows  signs  of 
septic  absorption.  The  gangrenous  part  is  generally  reddish  at  first,  and 
ultimately  becomes  black  ;  bullse  containing  dark  foul  fluid  form  over 
it,  and  it  crepitates  on  pressure  from  the  presence  of  gas.  The  soft 

67  F2 


68  INFLAMMATION   AND   ITS  SEQUELS 

parts  become  liquefied  and  separate  from  the  living  tissues  and,  in  the 
case  of  a  limb,  from  the  bone  as  a  dark,  slimy,  foul-smelling  mass.  If  the 
patient  lives,  there  is  marked  redness  round  the  edge  of  the  gangrene 
and  rapid  formation  of  a  line  of  demarcation.  Moist  gangrene  produces 
much  more  severe  disturbance  to  the  system  than  does  the  dry  form. 

TREATMENT — Local. — To  a  great  extent  the  treatment  of 
gangrene  depends  upon  the  cause"  of  the  particular  form,  but  it  will  be  of 
advantage  to  refer  here  to  some  general  principles.  From  what  has  been 
said  as  to  the  difference  in  the  symptoms  in  moist  and  dry  gangrene,  it  is 
evident  that  if  the  gangrenous  part  be  not  removed,  the  most  important 
point  in  the  treatment  is  to  try  to  prevent  the  septic  decomposition  which 
will  otherwise  take  place,  and  from  this  point  of  view  it  is  important  to 
favour  the  production  of  the  dry  form  as  much  as  possible.  Hence,  if 
it  be  suspected  that  gangrene  is  about  to  occur,  e.g.  when  the  circulation  in 
a  part  does  not  recover  reasonably  soon  after  embolism  or  ligature  of  an 
artery,  the  skin  should  be  shaved  and  thoroughly  disinfected  in  the  usual 
manner  (see  p.  100).  Special  attention  should  be  paid  to  the  nails,  which 
should  be  cut  short ;  the  folds  of  skin  under  and  about  them  should  be 
scrubbed  with  extreme  care.  It  should  be  borne  in  mind  that  the  organ- 
isms in  dust  have  to  be  guarded  against,  as  well  as  the  pyogenic  and 
other  pathogenic  organisms.  An  antiseptic  dressing  designed  to  prevent 
decomposition  and  at  the  same  time  to  allow  drying  of  the  part  should 
then  be  applied.  The  best  is  the  one  we  usually  employ  for  wounds,  viz. 
a  large  mass  of  cyanide  gauze  wrung  out  of  a  weak  antiseptic,  such  as  a 
i  in  4000  sublimate  solution,  outside  which  a  thick  layer  of  freshly  sterilised 
salicyclic  wool  is  applied.  This  dressing  permits  drying,  and  should  not 
be  disturbed  unless  it  be  desired  to  ascertain  whether  death  has  occurred, 
or  unless  discharge  comes  through.  Above  all  things  the  use  of  oint- 
ments should  be  avoided,  because  they  prevent  the  evaporation  of  the 
fluids,  and  so  keep  the  gangrenous  part  moist.  The  limb  should  be 
placed  on  a  water-pillow  and  slightly  elevated.  The  question  of 
amputation  will  be  considered  in  connection  with  the  individual  forms 
of  gangrene.  , 

General. — Concentrated  and  easily  digested  food,  such  as  various 
extracts  of  beef,  meat  juice,  lean  underdone  minced  meat,  chicken,  game, 
fish,  etc.,  must  be  administered.  Stimulants  are  usually  necessary ;  the 
best  is  brandy,  or,  if  there  be  no  diabetes,  champagne.  Drugs,  especially 
opium,  will  be  required  to  relieve  the  pain,  and  the  free  evacuation  of  the 
bowels  must  be  secured.  The  urine  should  be  examined  for  sugar,  diacetic 
acid,  acetone,  and  for  albumen,  and  if  any  of  those  compounds  be  found, 
the  necessary  diet  and  treatment  must  be  adopted. 

ETIOLOGICAL,  CLASSIFICATION".— We  may  now  pass  on 
to  the  consideration  of  the  etiological  classification  of  gangrene,  according 
to  which  there  are  three  great  varieties,  termed  respectively,  direct,  indirect, 
and  specific  gangrene.  By  direct  gangrene  is  meant  gangrene  of  a  part 


GANGRENE  69 

that  has  been  directly  subjected  to  an  injury,  as,  for  instance,  when  a 
cart-wheel  passes  over  the  foot  and  the  foot  dies.  In  indirect  gangrene  the 
gangrene  occurs  at  some  distance  from  the  cause,  as,  for  instance,  when 
the  foot  becomes  gangrenous  after  ligature  of  the  femoral  artery.  Specific 
gangrene  is  the  variety  due  to  specific  organisms,  for  example,  phagedena, 
acute  traumatic  gangrene,  and  the  like. 

DIRECT    GANGRENE. 

Direct  Gangrene  may  be  due  (i)  to  crushing  of  the  part,  (2)  to  pres- 
sure, (3)  to  acute  inflammation,  and  (4)  to  the  action  of  heat,  cold, 
or  caustics. 

Gangrene  due  to  Crushing. — The  most  common  cause  of  direct 
gangrene  is  severe  contusion  or  crushing,  as,  for  example,  when  a  limb 
has  been  run  over.  In  some  cases  the  parts  which  are  directly  subjected 
to  injury  may  lose  their  vitality  at  once  ;  in  other  cases,  where  septic 
inflammation  occurs  subsequently,  tissues  may  die  which  were  not  killed 
outright  by  the  injury  itself.  Further,  in  these  cases  there  may  be 
indirect  as  well  as  direct  gangrene ;  for  example,  when  the  wheel  of  a 
heavy  cart  passes  over  the  leg  it  may  rupture  the  blood-vessels  going 
to  the  foot,  and  so  lead  to  gangrene  of  the  toes  and  the  foot  as  well  as 
of  the  tissues  at  the  site  of  the  injury.  This  form  of  gangrene  is  moist, 
and  the  constitutional  symptoms  and  local  appearances  depend  upon 
whether  or  not  it  has  been  possible  to  render  the  part  aseptic  immediately 
after  the  injury. 

Treatment. — In  a  crush  affecting  the  extremities,  it  is  not  always 
easy  to  say  at  first  whether  the  injured  part  will  die  or  not ;  hence,  when 
the  state  of  the  patient  will  permit,  or  when  there  is  a  doubt  as  to  the 
extent  of  recovery,  it  is  well  to  wait  for  a  short  time  before  amputating. 
Meanwhile,  however,  measures  must  be  taken  to  prevent  or  diminish 
as  far  as  possible  the  putrefaction  of  any  portion  that  may  die.  The 
parts  should  therefore  be  disinfected  thoroughly  (see  p.  100),  and  a  dressing 
applied  and  left  on  for  twenty-four  or  forty-eight  hours,  till  it  is  seen 
how  much  tissue  is  going  to  die.  An  additional  advantage  of  delay  is 
that  the  patient  may  recover  from  the  shock  of  the  accident  before  he  is 
subjected  to  the  shock  of  the  amputation ;  one  of  the  great  dangers  of 
primary  amputation  is  the  addition  of  the  shock  of  the  operation  to 
that  caused  by  the  injury. 

The  question  of  amputation  depends  upon  the  amount  of  injury  done. 
In  some  cases  there  is  no  object  in  waiting,  because  it  can  be  seen  at 
once  that,  the  injury  is  irreparable.  For  example,  when  not  only  the  skin 
but  also  the  bones,  vessels,  and  nerves  are  destroyed,  there  can  be  no 
question  as  to  the  advisability  of  amputation.  On  the  other  hand, 
if  the  blood-vessels  and  nerves  be  intact,  it  may  still  be  possible  to  save 
the  limb,  even  though  the  bones  be  extensively  crushed,  and  a  large 
area  of  skin  destroyed,  provided  always  that  the  wound  be  rendered 


7o  INFLAMMATION  AND   ITS  SEQUELS 

aseptic.  Formerly,  amputation  was  performed  if  the  bones  were  exten- 
sively injured,  even  though  the  large  vessels  and  nerves  were  intact ;  but 
sufficient  experience  has  shown  us  that  a  large  number  of  cases  of 
compound  fracture  can  now  be  safely  treated  under  antiseptic  precau- 
tions, without  recourse  to  amputation.  Formerly,  also,  it  was  held 
best  to  amputate  when  large  portions  of  the  skin  were  lost,  even  though 
both  vessels  'and  bones  were  intact,  because  violent  inflammation  and 
septic  absorption  often  occurred  and  led  to  a  fatal  result ;  if  the  patient 
survived,  either  the  wound  did  not  heal  at  all,  owing  to  the  difficulty  of 
contraction,  or  if  it  did,  the  contraction  caused  great  deformity,  and 
rendered  the  extremity  useless.  At  the  present  time,  however,  these 
risks  can  be  avoided  to  a  certain  extent,  and  amputation  is  not  always 
necessary  even  when  extensive  areas  of  skin  are  lost.  In  the  first  place, 
if  asepsis  be  obtained,  it  frequently  happens  that  a  considerable  amount 
of  tissue  which  would  otherwise  have  died  retains  its  vitality.  In  the 
second  place,  the  great  contraction  which  would  otherwise  result  is 
avoided  by  the  use  of  skin-grafting  when  the  wound  has  begun  to  granu- 
late (see  p.  52),  while  at  the  same  time  wounds  can  be  got  to  heal  which 
otherwise  would  not  heal  at  all.  In  patients  who  are  very  old,  or  much 
broken  down  in  health,  and  to  whom  a  long  confinement  to  bed  would 
be  injurious,  more  particularly  if  they  are  the  subjects  of  renal  disease, 
amputation,  however,  is  often  the  safest  procedure.  When  diabetes  is 
present,  the  cases  in  which  an  attempt  should  be  made  to  save  the  limb 
are  comparatively  few. 

Gangrene  due  to  Pressure. — Another  cause  of  direct  gangrene 
is  continued  pressure,  and  it  is  very  important  to  remember  this  when 
a  patient  has  to  be  kept  in  one  position  for  a  long  time.  Under  such 
circumstances,  the  parts  subjected  to  pressure  are  apt  to  die,  and  this 
is  especially  the  case  with  soft  parts  over  bony  prominences,  such  as  the 
sacrum,  or  those  subjected  to  pressure  against  the  edge  of  a  splint.  This 
is  the  condition  known  as  bed-sore.  The  gangrene  in  these  cases  is  moist. 

Treatment. — The  treatment  of  bed-sore  resolves  itself  into  (a)  prophy- 
laxis, (6)  treatment  when  bed-sore  is  threatened,  and  (c)  when  it  is 
actually  present. 

Prophylaxis. — The  essential  points  in  the  prophylactic  treatment  are  in 
the  first  place  to  avoid  continuous  pressure,  or  to  so  vary  or  diffuse  it  that 
it  shall  not  tell  too  long  or  too  injuriously  on  one  part,  and,  in  the 
second  place,  to  keep  the  skin  dry.  The  first  indication  is  carried  out  by 
frequently  altering  the  position  of  the  patient  or  the  part,  or  by  so  arranging 
matters  that  the  pressure  shall  not  tell  on  any  bony  prominence.  For 
instance,  the  patient  may  lie  on  a  ring-pillow,  the  opening  in  the  pillow 
being  opposite  the  part  which  is  to  be  relieved  of  pressure. 

Another,  and  in  most  cases  the  best,  way  is  to  place  the  patient  on  a 
water-pillow  or  a  water-bed,  so  that  the  pressure  does  not  remain  localised 
to  any  one  point,  but  is  distributed  over  a  considerable  area.  When  a 


GANGRENE  71 

water-pillow  is  used,  it  must  be  neither  over-  nor  under-filled ;  in  the  former 
case,  it  becomes  hard  and  convex,  and  does  not  apply  itself  evenly  to 
the  skin,  so  that  as  much  pressure  is  exerted  upon  the  part  as  if  there 
were  no  water-pillow  at  all.  On  the  other  hand,  if  there  be  too  little 
water,  the  patient  is  not  properly  supported,  and  the  part  comes  into 
contact  with  the  bed.  A  good  method  of  testing  the  filling  is  to  bear 
one's  whole  weight  on  the  pillow  by  pressing  the  two  spread-out  hands 
in  the  centre ;  if  they  just  touch  the  other  side  of  the  water-pillow,  the 
patient's  body  will  float  when  laid  upon  it.  A  large  water-pillow  must 
be  filled  upon  the  bed.  The  water  should  be  tepid  when  introduced, 
and  it  ought  to  be  changed  every  three  or  four  days,  otherwise  it  is  apt  to 
become  foul.  The  pillow  is  covered  by  a  draw-sheet,  and  great  care  should 
be  taken  that  this  does  not  become  wrinkled.  When  the  pressure  is  only 
over  a  limited  area,  or  the  patient  is  a  small  child,  an  air-cushion  may  be 
used  for  the  same  purpose. 

A  second  point  in  the  avoidance  of  bed-sore  is  to  see  that  the  parts 
most  exposed  to  pressure  are  kept  dry.  The  patient  should  be  turned 
over  twice  a  day,  and  the  sacral  or  any  other  region  subjected  to  pres- 
sure, should  be  carefully  washed  and  dried  ;  after  this  the  part  should  be 
rubbed  gently  with  a  soft  towel  so  as  to  improve  the  circulation,  and  the 
nutrition  of  the  tissues  should  be  further  promoted  and  the  epidermis 
hardened  by  the  application  of  some  stimulating  fluid,  such  as  spirits  of 
wine  or  whisky.  The  spirits  of  wine  is  allowed  to  dry  on  the  skin, 
which  is  then  gently  chafed,  and  subsequently  dusted  with  boric  acid 
powder. 

When  a  bed-sore  is  threatening — that  is  to  say,  when  the  skin  is  becoming 
red — the  same  measures  should  be  continued,  but  it  is  well  to  relieve  the 
pressure  entirely  by  placing  a  ring-pillow  around  the  part  on  the  surface 
of  the  water-bed.  When  the  skin  is  becoming  raw,  lint  spread  with  equal 
parts  of  balsam  of  Peru  and  resin  ointment  is  a  good  application ;  it  should 
be  renewed  night  and  morning,  after  the  part  has  been  washed,  dried,  and 
rubbed  with  alcohol. 

When  a  bed-sore  has  formed,  the  slough,  and  subsequently  the  sore, 
must  be  kept  as  aseptic  as  possible.  When  the  patient  is  lying  on  the 
affected  area  it  is  impossible  to  carry  out  one  of  the  chief  principles  in 
the  treatment  of  gangrene,  namely,  to  favour  the  drying  of  the  slough, 
and,  that  being  the  case,  there  is  no  objection  to  the  use  of  antiseptic 
ointments.  Full-strength  boric  or  eucalyptus  ointment  may  be  used  and 
should  be  changed  for  the  half-strength  boric  ointment  when  the  slough 
has  separated.  Balsam  of  Peru,  either  alone  or  mixed  with  an  equal 
quantity  of  white  of  egg,  is  also  a  good  dressing.  As  soon  as  possible 
the  patient  should  be  made  to  lie  upon  one  side,  when  the  sore  will  usually 
begin  to  heal,  unless  the  general  condition  be  extremely  feeble.  The 
patient's  general  nutrition  should  be  promoted  by  the  administration  of 
light  and  easily  digested  food  and  stimulants. 


72  INFLAMMATION  AND  ITS  SEQUELS 

Gangrene  due  to  Acute  Inflammation. — When  an  acute  inflam- 
mation occurs  in  dense  tissues,  and  especially  when  it  ends  in  suppuration, 
not  only  may  the  toxins  kill  the  tissues,  but  the  thrombosis  and  the  pres- 
sure of  the  exudation  on  the  blood-vessels  may  also  lead  to  their  death 
from  insufficient  blood-supply.  The  best  examples  of  this  are  acute 
necrosis  following  acute  suppurative  periostitis  and  osteomyelitis,  and  the 
sloughs  which  occur  in  the  skin  in  boils  and  carbuncles.  These  cases  will 
be  dealt  with  under  their  respective  headings ;  we  need  only  say  here  that 
early  free  incisions  are  called  for. 

Gangrene  due  to  the  Action  of  Heat,  Cold,  or  Caustics.— 
The  treatment  of  this  form  of  gangrene  is  practically  that  of  burns  and 
scalds  and  frostbite  (see  Chap.  VIII.). 

INDIRECT    GANGRENE. 

In  the  indirect  form  of  gangrene  the  causal  agent  does  not  act  directly 
upon  the  part  which  dies,  and  this  form  of  the  affection  may  be  divided 
into  the  four  following  groups,  viz. :  (i)  gangrene  due  to  gradual  diminu- 
tion in  the  calibre  of  the  blood-vessels ;  (2)  gangrene  due  to  the  sudden 
obstruction  of  the  blood-vessels ;  (3)  gangrene  due  to  imperfect  innerva- 
tion;  and  (4)  gangrene  due  to  general  causes,  such  as  diabetes,  acute 
fevers,  the  use  of  ergot,  etc. 

Gangrene  due  to  the  Gradual  Diminution  in  the  Calibre  of 
the  Blood-vessels. — Dry  or  senile  gangrene  is  the  typical  example  of  this 
form.  The  changes  leading  to  senile  gangrene  affect  the  arteries,  and  are 
in  part  gradual  diminution  in  the  calibre  of  the  blood-vessels,  and  in 
part  rigidity  of  then*  walls,  so  that  they  do  not  dilate  and  contract  in  con- 
formity with  the  needs  of  the  tissues.  Anything  which  leads  to  endarteritis 
will  favour  the  production  of  this  form  ;  for  example,  alcoholism  is  a 
very  potent  cause  of  endarteritis,  as  are  also  chronic  nephritis,  diabetes, 
and  syphilis,  and  these  are  among  the  chief  causes  of  senile  gangrene. 
Another  common  cause  is  atheroma,  which  is  a  chronic  inflammation 
of  the  deeper  part  of  the  internal  coat  of  the  artery,  leading  to  irregular 
thickening  and  rigidity,  diminution  in  calibre,  and  even  in  some  cases 
calcification  of  the  middle  coat.  In  atheroma  and  endarteritis  a  further 
cause  of  gangrene  is  the  readiness  with  which  thrombosis  occurs  in  the 
affected  vessels,  and  leads  to  complete  blocking  of  their  lumen. 

It  is  evident  that  in  most  cases  certain  symptoms,  due  to  imperfect 
blood-supply,  will  precede  the  occurrence  of  the  gangrene.  Thus,  one 
of  the  chief  complaints  of  the  patient,  even  long  before  the  gangrene 
occurs,  is  great  coldness  and  perverted  sensation  in  the  feet.  He  suffers 
much  from  tingling,  he  does  not  feel  the  ground  properly  when  he  walks, 
he  feels,  in  fact,  as  if  there  were  something  soft  between  his  feet  and 
the  ground.  After  these  symptoms  have  lasted  some  time,  something 
occurs  which  sets  up  a  little  inflammation  about  the  foot ;  possibly  a 
blister  forms  as  the  result  of  tight  boots,  or  a  corn  suppurates,  or  the 


GANGRENE 


73 


tissues  are  injured  in  paring  a  corn.  Some  trivial  cause  leads  to  inflam- 
mation, and,  on  account  of  the  weak  state  of  the  tissues,  this  is  followed 
by  gangrene  ;  had  the  tissues  been  healthy,  the  inflammation  would 
have  passed  off  without  any  trouble.  The  first  sign  of  gangrene  is  usually 
a  small  black  spot  which  occurs  in  the  centre  of  the  inflamed  area.  The 
gangrene  progresses  very  slowly,  and  it  may  be  weeks  or  even  months 
before  more  than  the  toes  die.  The  appearances  are  those  typical  of  dry 
gangrene  (see  p.  67).  The  patient  for  some  time  remains  in  a  good  state 
of  health,  and  his  chief  complaint  is  the  pain  he  suffers,  which  may  be 
intense.  As  the  result  of  this,  he  becomes  sleepless,  and  after  a  time  his 
pulse  loses  its  fulness,  and  he  gets  restless.  If  the  disease  be  allowed  to 
run  its  course,  the  patient  will  in  most  cases  die,  worn  out  by  pain  and 
want  of  sleep,  or  from  some  septic  complication  which  has  its  origin  at 
the  line  of  demarcation.  In  some  cases,  however,  recovery  takes  place, 
the  line  of  demarcation  forming  very  slowly,  and  the  dead  part  being  cast 
off  gradually. 

Treatment. — In  describing  the  treatment  of  this  form  of  gangrene, 
it  is  necessary  to  consider  the  prophylactic  treatment  as  well  as  that  caUed 
for  when  gangrene  has  actually  set  in.  When  an  elderly  patient  com- 
plains of  symptoms  indicating  imperfect  circulation  in  the  foot,  and  when 
on  examination  the  vessels  are  found  to  be  thickened,  or  devoid  of  pulsa- 
tion, pains  should  be  taken  to  explain  the  danger,  and  to  point  out  how 
slight  are  the  injuries  which  may  precipitate  the  onset  of  gangrene.  The 
patient  must  not  wear  tight  boots,  and  should  be  specially  cautioned  not 
to  neglect  any  injury  to  the  foot,  however  trivial  it  may  appear.  Above 
all  he  should  be  warned  not  to  place  his  feet  in  hot  baths  or  before  a  very 
warm  fire,  for  the  heat  is  apt  to  bring  on  gangrene  owing  to  the  imperfect 
state  of  the  circulation.  If  his  feet  be  very  cold,  he  may  place  them  in 
a  bath  of  from  80°  to  85°  F.,  tested  by  a  thermometer,  and  then 
have  them  gently  rubbed  with  a  soft  bath-towel.  He  should  wear  warm 
stockings,  and  warm,  light,  fur-lined  shoes  or  slippers.  In  bed  he  should 
wear  thick  bed-socks,  and  the  bed  may  be  warmed  with  hot  bottles, 
which  however  should  either  be  taken  away  before  he  gets  into  bed,  or 
removed  to  such  a  distance  that  his  feet  cannot  reach  them ;  in  all  cases 
the  bottles  should  be  wrapped  up  in  thick  flannel.  The  diet  must  be 
nourishing,  and  plenty  of  fresh  air  and  light  exercise  should  be  insisted 
upon. 

Directly  gangrene  has  occurred,  or  rather  as  soon  as  it  is  evident  that 
it  is  inevitable,  the  first  essential  in  the  treatment  is  to  disinfect  the  part 
thoroughly  and  to  favour  evaporation  of  fluid  from  the  tissues  (see  p.  68). 
Above  all  things,  ointments,  carbolic  oil,  and  other  greasy  dressings  should 
be  avoided,  and  only  those  employed  which  permit  drying  of  the  part ; 
cyanide  gauze  next  the  skin,  with  some  sterilised  salicylic  wool  outside, 
forms  the  best  dressing.  The  patient  should  remain  in  a  recumbent 
position,  with  the  foot  kept  warm  and  slightly  elevated.  The  strength 


74  INFLAMMATION  AND  ITS  SEQUELAE 

must  be  supported  by  generous  diet  and  fresh  air,  obtained  if  possible  by 
wheeling  the  patient  out  in  a  suitable  reclining  chair  every  day.  The 
heart's  action  must  be  assisted  as  far  as  possible,  and  for  this  purpose 
the  tinct.  nucis  vomicae  in  5-minim  doses,  combined  with  5  minims  of  the 
tinct.  digitalis,  three  times  a  day,  is  valuable.  The  free  administration 
of  opium  is  called  for  in  order  to  relieve  the  pain  ;  this  drug  has  a  very 
beneficial  effect  in  many  cases  of  senile  gangrene,  even  when  there  is  - 
no  diabetes.  It  probably  acts  mainly  by  relieving  the  pain,  and  thus 
enabling  the  patient  to  get  sound  rest  and  sleep  ;  but  some  authorities 
consider  that  opium  has  a  specific  action  in  gangrene.  It  should  be  given 
four  times  a  day,  beginning  with  10  to  12  minims  of  laudanum,  or  pil. 
saponis  co.  (gr.  5-10),  and  gradually  increasing  the  dose.  At  the  same 
time  the  bowels  must  be  kept  open  by  the  use  of  one  of  the  natural  aperient 
mineral  waters,  or  by  Seidlitz  powders  and  enemata.  Stimulants  will 
probably  be  required,  certainly  in  the  later  periods  ;  whisky  and  brandy, 
in  amounts  from  3  to  6  ounces  daily,  are  the  best. 

At  an  early  period  the  question  of  amputation  must  be  carefully  con- 
sidered. The  old  rule  was  that  amputation  should  never  be  performed 
in  senile  gangrene,  but  that  the  part  should  be  allowed  to  drop  off,  the 
utmost  surgical  interference  allowed  being  to  snip  through  dead  tendons 
or  bones  ;  on  no  account  was  interference  with  the  living  tissues  allowable. 
The  reason  for  this  was  that  before  the  antiseptic  era  acute  inflamma- 
tion almost  always  followed  amputation,  and  when  inflammation  occurs 
in  these  weak  tissues  it  is  almost  certain  to  lead  to  sloughing  of  the 
flaps  and  more  rapid  progress  of  the  gangrene,  which  then  becomes  of 
the  moist  variety.  At  the  present  time,  however,  it  is  easy  to  avoid 
this  inflammatory  disturbance,  and  therefore  the  rules  as  regards  amputa- 
tion in  senile  gangrene  are  completely  altered.  It  is  now  not  so  much  a 
question  of  recurrence  of  gangrene  in  the  stump,  as  whether  the  patient 
has  sufficient  recuperative  power  to  recover  from  the  operation.  In 
cases  where  the  answer  to  this  question  is  doubtful,  it  must  be  remem- 
bered that  the  patient,  if  left  alone,  will  almost  certainly  die  from  the 
senile  gangrene,  and  therefore  that  amputation  offers  practically  the  only 
chance.  By  operating  early,  and  by  amputating  well  above  the  dead 
part,  the  patient's  strength  is  preserved,  he  is  not  worn  out  by  pain  and 
loss  of  sleep,  and  he  is  in  a  much  better  condition  to  survive  the  operation 
than  if  it  were  delayed.  The  only  difficulty  is  that  it  is  not  always 
possible  to  gauge  how  far  the  process  will  extend ;  as  a  rule,  this  can  be 
determined  by  ascertaining  the  point  at  which  pulsation  in  the  main 
vessels  ceases.  In  some  rare  cases  in  which  the  artery  can  be  felt  beating 
strongly  at  the  ankle  joint,  amputation  may  be  performed  there,  prefer- 
ably by  means  of  an  internal  flap.  In  most  cases  the  pulsation  at  the 
ankle  is  very  slight,  if  present  at  all,  and  when  it  cannot  be  felt  there 
the  best  place  for  amputation  is  the  region  of  the  knee.  The  thrombus 
which  forms  in  the  diseased  vessels  when  the  amputation  is  done  through 


GANGRENE  75 

the  ankle  is  apt  to  extend  upwards  as  far  as  the  knee  and  lead  to  gangrene 
of  the  flaps.  Generally,  therefore,  amputation  through  the  condyles  of 
the  femur  or  the  lower  third  of  the  thigh  is  preferable. 

Gangrene  due  to  Sudden  Obstruction  of  the  Blood-vessels. — 
This  may  be  the  result,  firstly,  of  pressure  outside  these  structures,  for 
example,  after  ligature,  the  application  of  tight  bandages,  pressure  from 
the  fractured  ends  of  bones,  etc. ;  secondly,  of  rupture  of  their  walls,  as  in 
dislocations  or  in  the  attempted  reduction  of  dislocations  ;  and,  thirdly, 
of  blocking  of  their  lumen,  as  by  an  embolus,  followed  by  thrombosis. 

In  the  first  two  cases  the  vein  may  be  blocked  as  well  as  the  artery, 
and  while  this  makes  no  essential  difference  in  regard  to  treatment,  the 
symptoms  vary  somewhat.  When  the  obstruction  is  primarily  arterial, 
the  first  thing  noticed  is  that  the  limb  below  becomes  pallid  from  absence 
of  blood ;  it  then  assumes  a  dark  livid  colour,  and  the  various  changes 
already  described  as  characteristic  of  moist  gangrene  follow.  In  em- 
bolism there  is,  in  addition  to  the  sudden  whiteness  of  the  limb,  violent 
pain  at  the  point  where  the  embolus  has  been  arrested,  and  this  is  a 
valuable  sign  as  showing  where  the  block  has  occurred.  When,  how- 
ever, the  case  afterwards  comes  to  amputation  it  must  not  be  assumed 
that  the  seat  of  pain  is  the  upper  limit  of  the  obstruction,  because  throm- 
bosis takes  place  subsequently  to  the  embolism,  and  may  extend  upwards 
for  a  considerable  distance.  If  there  be  venous  as  well  as  arterial 
obstruction  in  the  first  instance,  the  part  below  remains  dark  and 
becomes  redematous  very  quickly. 

Treatment.— This  depends  on  the  "extent  of  the  gangrene,  and  the 
great  question  for  consideration  is  that  of  amputation.  Before  deciding 
this  point,  sufficient  time  should  be  allowed  to  elapse  to  enable  the 
surgeon  to  see  how  much  of  the  collateral  circulation  will  be  established, 
because,  although  at  first  the  part  may  appear  white  and  dead,  a 
very  considerable  portion,  or  indeed  the  whole,  may  recover  as  the 
result  of  the  enlargement  of  the  anastomotic  circulation.  While  waiting 
however,  precautions  must  be  taken  not  to  allow  putrefaction  to  occur, 
and  also  to  permit  drying  (see  p.  68).  If  gangrene  occur,  the  part  soon 
becomes  dusky  and  remains  cold.  The  finger  firmly  pressed  into  the 
skin  makes  no  difference  to  the  colour;  whereas,  if  the  circulation  be 
maintained,  the  part  pressed  upon  becomes  white  and  regains  its  original 
appearance  when  the  pressure  is  discontinued.  When  recovery  takes 
place,  it  does  so  within  the  first  twenty-four  hours,  and  amputation 
should  be  practised  without  further  delay  when  it  is  certain  how  much 
is  going  to  die.  There  is  no  necessity  to  wait  for  the  formation  of  a 
line  of  demarcation. 

The  point  at  which  amputation  should  be  done  depends  on  the 
anatomy  of  the  arteries  and  on  the  extent  of  recovery.  It  should,  how- 
ever, be  borne  in  mind  that  the  gangrene  is  generally  less  extensive  in 
the  skin  than  in  the  deeper  parts,  and  therefore  if  the  flaps  be  cut  close 


76 


INFLAMMATION   AND  ITS  SEQUELS 


I 


to  the  gangrenous  part,  the  incision  will  probably  go  into  dead  tissues 
as  it  is  deepened.  Hence  an  interval  of  at  least  three  inches  should 
intervene  between  the  line  of  gangrene  and  the  amputation  incision  (see 
Fig.  22).  In  many  cases,  however,  amputation  is  done  higher  up  than 
this  on  account  of  the  better  stump  obtained,  or  on  account  of  the 
better  anastomotic  circulation.  When  there  is 
blocking  of  the  veins  as  well  as  of  the  arteries, 
the  chances  of  restoration  of  the  local  circulation 
are  less,  but  the  rules  of  treatment  are  the  same. 
Gangrene  due  to  Imperfect  Innervation.— 
When  a  limb  is  paralysed,  its  nutrition  is  almost 
always  deficient,  and  such  limbs  are  especially 
liable  to  the  formation  of  bed-sores  and  gangrene 
from  pressure.  In  hemiplegia  also,  when  the 
patient  is  lying  absolutely  still,  he  is  extremely 
liable  to  suffer  from  bed-sores,  which  are  worse  on 
the  paralysed  side  than  on  the  sound  one.  Again, 
if  extension  be  applied  to  a  paralysed  limb  and 
to  a  sound  one,  there  is  much  greater  liability  for 
sloughs  to  form  under  the  extension  plaster  on 
the  paralysed  limb  than  on  the  sound  side. 

The  gangrene  that  occurs  in  these  cases  gene- 
rally comes  on  very  quickly.  It  is  moist,  and  is 
often  spoken  of  as  an  acute  bed-sope,  and  it  is  very 
important  to  remember  that  under  such  circum- 
stances the  greatest  care  should  be  taken  to  avoid 
even  the  slightest  pressure.  The  part  must  be 
examined  frequently  to  see  that  its  condition  is 
good,  and  the  limb  should  be  kept  warm  and 
slightly  elevated ;  should  sloughing  occur,  the 
case  must  be  treated  like  one  of  bed-sore  (see 
p.  70). 

There  is  another  form  of  gangrene  in  con- 
nection with  nervous  derangements  termed  sym- 
metrical gangrene  or  'Raynaud's  Disease.'  This 
form  differs  from  senile  gangrene,  which  it 
some  respects,  in  that  it  is  always  bilateral,  while 
senile  gangrene  is  often  one-sided ;  that  it  more  often  affects  the 
fingers  than  the  toes  ;  that  it  is  much  more  limited  both  in  extent 
(generally  not  reaching  beyond  the  phalanges)  and  in  depth  (seldom 
going  deeper  than  the  skin)  ;  and  that  in  '  Raynaud's  disease  '  the 
blood-vessels  are  structurally  normal,  whereas  in  senile  gangrene 
they  are  thickened  and  hard.  '  Raynaud's  disease '  occurs  chiefly 
in  women  of  pronounced  neurotic  type  between  eighteen  and  thirty 
years  of  age ;  though  often  associated  with  uterine  and  menstrual 


FIG.  22.  —  DIAGRAM  TO 
ILLUSTRATE  THE  PRINCIPLES 
OF  AMPUTATION  FOR  GAN- 
GRENE OF  THE  LEG. — The 
shaded  portion  represents 
the  extent  of  the  gangrene, 
which  is  seen  to  extend 
further  up  the  limb  in  the 
deeper  tissues  than  in  the 
skin.  The  unbroken  lines 
above  this  represent  the  in- 
cisions which  must  be  made  in 
order  to  remove  the  whole  of 
the  gangrenous  area.  In  many 
cases  much  more  healthy 
tissue  must  be  removed. 


resembles    in 


GANGRENE 


77 


troubles,  there  is  little  evidence  of  a  closer  causal  connection  than  that 
both  are  referable  to  profound  vaso-motor  disturbance.  The  attacks 
are  often  brought  on  by  cold,  and  are  most  commonly  met  with  during 
the  winter  months.  It  is  probable  that  in  some  cases  the  disturbance  is 
in  the  vaso-motor  centres,  in  others  in  the  vaso-motor  nerves,  and  yet 
again  in  others  in  both  centres  and  fibres  simultaneously.  The  initial 
effect  would  seem  to  be  spasm  of  the  arterioles  of  the  extremities.  In  the 
asphyxial  stage  there  is  vaso-paresis  of  capillaries  and  veins,  side  by  side 
with  or  following  upon  arterial  vaso-constriction.  Not  only  the  ischaemia 
of  the  spasmodic  stage,  but  also  the  hyperaemia  of  the  asphyxial  stage 
may  terminate  in  gangrene. 

Certain  phenomena  precede  the  gangrene.  The  extremity  affected 
may  become  quite  white  from  contraction  of  the  blood-vessels ;  follow- 
ing this,  or  occurring  without  any  preliminary  pallor,  the  parts  may 
become  of  a  deep  purple  colour,  as  though  dipped  in  ink.  This  is  evidently 
due  to  a  local  venous  stasis  and  it  may  last  for  a  day  or  two,  and  may 
or  may  not  lead  to  dry  gangrene.  The  darkness  of  the  extremities  just 
noted  continues  for  some  days,  the  pain  and  other  symptoms  increase, 
and  small  bulke  may  possibly  form  ;  indeed,  in  the  case  of  the  hand,  it 
often  looks  as  if  the  patient  must  lose  all  the  fingers.  Ultimately  the 
circulation  improves,  and  as  a  rule  the  final  result  is  that  only  a  small  piece 
of  tissue  dries  up,  and  ultimately  separates.  The  process  is  slow  and  takes 
from  twenty  days  to  ten  months  from  the  commencement  of  the  gangrene 
to  the  separation  of  the  slough.  The  condition  is  very  apt  to  recur. 

Local  Treatment. — In  the  treatment  of  the  local  condition,  the  first 
place  must  be  given  to  stimulation  by  the  electrical  current.  For  this 
purpose  the  constant  current  may  be  used,  and,  as  recommended  by  Sir 
Thomas  Barlow,  the  extremity  of  the  affected  limb  should  be  immersed 
in  a  basin  of  salt  and  water.  One  pole  of  the  constant  current  battery  is 
placed  on  the-  upper  part  of  the  limb,  whilst  the  other  is  immersed  in  the 
fluid  in  the  basin.  As  many  cells  may  be  employed  as  the  patient  can 
comfortably  bear,  and  the  current  is  made  and  broken  twenty  to  thirty 
times  per  minute,  so  as  to  get  repeated  muscular  contractions.  When 
several  extremities  are  affected,  and  it  is  possible  to  obtain  it,  the  com- 
plete electric  bath  is  best.i  This  should  be  of  porcelain,  earthenware, 
or  wood,  about  5  ft.  6  in.  long,  and  the  patient  should  be  immersed  in 
it  up  to  the  neck.  The  water  should  be  just  under  100°  F.  The  elec- 
trodes are  large  flat  copper  plates  about  a  foot  square  ;  they  are  placed 
at  the  head  and  foot  of  the  bath.  The  shoulders  should  not  touch  the 
electrode,  the  feet  may  be  allowed  to  do  so.  The  current  at  first  should 
not  exceed  100  milliamperes  ;  after  a  few  baths  it  may  be  gradually 
raised  to  150  or  200,  and  it  should  not  be  turned  on  until  the  patient  has 
been  in  the  bath  some  little  time,  and  then  only  very  gradually.  The 

1  For  further  information  on  these  points  the  reader  is  referred  to  Dr.  Lewis 
Jones's  Medical  Electricity  (H.  K.  Lewis,  London). 


78  INFLAMMATION  AND   ITS  SEQUELS 

bath  should  last  about  fifteen  minutes,  and  should  be  repeated  daily  for 
the  first  week  ;  then  three  times  a  day  until  about  a  dozen  to  fifteen 
baths  have  been  taken.  This  is  generally  sufficient  to  produce  con- 
siderable improvement.  Another  method  is  to  rub  the  limb  over  with 
two  sponge  electrodes  held  a  short  distance  apart ;  this  is  useful  in 
reducing  the  pain  that  is  usually  present.  This  method  may  also  be 
employed,  when  gangrene  has  actually  occurred,  for  the  relief  of  pain  in 
the  surrounding  parts. 

The  application  of  the  current  generally  produces  a  somewhat  pro- 
fuse perspiration,  and  is  usually  unaccompanied  by  pain ;  an  important 
change,  showing  that  the  current  is  doing  good,  is  that  the  hands  fre- 
quently become  moist,  where  previous  to  its  application  they  were  harsh 
and  dry.  This,  by  Raynaud  himself,  is  considered  one  of  the  most 
favourable  elements  of  prognosis.  He  also  points  out  that  when  this 
treatment  has  been  followed  for  some  days,  and  improvement  has 
distinctly  commenced,  certain  unpleasant  effects  may  begin  to  manifest 
themselves ;  for  instance,  headache,  which  is  intensified  by  the  passage 
of  the  current,  a  painful  sensation  of  constriction  in  the  throat,  and 
general  excitement.  He  states  that  these  symptoms  are  not  serious,  but 
that,  should  they  occur,  it  is  proper  to  diminish  the  strength  of  the  current. 

Another  very  useful  form  of  treatment,  and  one  that  may  often  be 
advantageously  combined  with  the  use  of  electricity,  is  careful  friction 
or  shampooing.  In  some  cases  this  cannot  be  borne  by  the  patient, 
however  carefully  it  be  carried  out ;  but  it  will  generally  be  found  that 
after  electricity  has  been  employed  for  some  little  time  in  the  manner 
just  recommended,  the  parts  are  sufficiently  free  from  tenderness  to 
bear  careful  shampooing  with  the  hand  encased  in  soft  flannel  or  other 
suitable  gloves.  After  a  time  friction  by  the  naked  hand,  anointed 
with  some  simple  lubricant,  may  be  substituted.  This  may  also  be 
used  with  advantage  for  those  cases  in  which,  after  repeated  attacks  of 
gangrene,  the  limb  has  become  contracted  and  anchylosis  has  occurred. 
Under  these  circumstances  it  is  of  course  used  with  a  different  object, 
namely,  to  promote  the  nutrition  of  the  muscles  and  to  facilitate  the 
movement  of  the  various  joints.  The  friction  may  be  carried  out 
immediately  after  the  application  of  the  current,  and  may  be  repeated 
more  than  once  during  the  day  if  the  patient  experiences  definite  relief 
from  its  use. 

In  cases  in  which,  during  the  height  of  the  spasm,  there  is  intense 
pain,  considerable  relief  seems  to  be  afforded  by  the  application  of 
slight  cold,  and  this  appears  to  be  more  effectual,  at  any  rate  in  abating 
the  pain,  than  the  use  of  hot  fomentations.  For  this  purpose  the  ex- 
tremities may  be  covered  with  a  piece  of  lint  dipped  in  eau  de  Cologne, 
or  some  similar  spirit,  diluted  with  water.  In  cases  of  extremely  grave 
local  asphyxia,  when  gangrene  was  obviously  impending,  Raynaud 
made  use  of  the  application  of  leeches  with  apparently  satisfactory 


GANGRENE  79 

results.  This  method,  however,  should  not  be  employed  except  when 
the  condition  is  grave,  as  with  it  septic  complications  are  not  at  all 
unlikely  to  occur.  Whenever  it  appears  imperative  to  relieve  the  local  con- 
gestion, we  should  prefer  to  use  scarifications  (after  the  skin  has  been 
rigorously  purified)  followed  by  warm  fomentations  to  encourage  bleeding. 

General  Treatment. — Much  may  be  done  to  prevent  recurrence  by 
attention  to  the  general  health.  Warm  clothing  and  avoidance  of  cold 
are  of  prime  importance  ;  only  second  in  importance  to  these  are  nourish- 
ing food  and  regular  daily  exercise.  If  there  be  a  marked  hysterical 
condition,  the  patient  may  be  treated  by  massage  and  careful  feeding, 
combined  with  isolation,  as  recommended  by  Weir  Mitchell.  Apart 
from  this,  some  drugs  seem  to  be  of  benefit,  although  there  is  apparently 
none  that  can  be  looked  upon  as  having  any  specific  effect  upon  the 
affection.  Chief  among  these  is  opium,  which  is  useful  in  some  cases. 
Possibly  it  may  allay  the  spasm  to  a  certain  extent ;  at  any  rate  it  calms 
the  agonising  pain  that  is  often  present.  Quinine  in  doses  of  four  grains 
three  times  a  day  is  also  of  use  both  constitutionally  and  for  the  local 
condition.  If  there  be  pronounced  anaemia,  iron  and  arsenic  may  be 
administered,  the  former  as  Blaud's  preparation  in  capsules  of  five  to 
ten  grains  three  times  a  day,  the  latter  in  the  form  of  Fowler's  solution, 
beginning  with  a  dose  of  three  drops  upon  a  piece  of  sugar  taken  three 
times  a  day,  and  gradually  increased  until  twelve  or  fifteen  minims  are 
taken  at  a  time.  Nitrite  of  amyl,  nitro-glycerine  and  nitrite  of  sodium 
have  been  recommended  from  a  theoretical  consideration  of  their  action, 
but  apparently  without  any  marked  benefit.  Any  uterine  or  ovarian 
trouble  present  should  receive  appropriate  treatment.  When  actual 
sloughing  has  taken  place,  the  treatment  already  described  for  dry  gan- 
grene must  be  carried  out,  antiseptic  dressings  being  used,  and  the  part 
allowed  to  dry  up.  Amputation  is  rarely  necessary. 

Gangrene  due  to  General  Causes. — This  form  of  indirect  gangrene 
is  in  some  ways  the  most  important  of  all.  Three  varieties  may  be  men- 
tioned, namely  (a)  gangrene  in  connection  with  diabetes,  (b)  gangrene 
after  acute  fevers,  and  (c)  gangrene  following  the  use  of  ergot. 

Diabetic  Gangrene. — There  are  two  ways  in  which  diabetes  may 
be  related  to  gangrene.  First,  there  is  the  death  of  the  part  directly 
dependent  upon  the  presence  of  diabetes,  or  the  true  '  diabetic  gangrene  ' ; 
second,  there  is  gangrene  from  some  other  cause  taking  place  in  a  patient 
who  has  glycosuria.  The  presence  of  glycosuria  affects  the  progress 
of  the  gangrene  in  a  marked  degree ;  it  spreads  with  greater  rapidity, 
there  is  more  inflammation  around  the  gangrenous  part,  and  the  gangrene, 
if  dry  at  first,  soon  becomes  moist.  The  patient  generally  dies  either  of 
some  septic  complication — such  as  a  rapidly-spreading  diffuse  cellulitis 
or  a  general  septicaemia — or  of  diabetic  coma,  either  following  operation 
or  occurring  independently.  Sometimes  the  gangrenous  process  is  slow 
and  the  patient  dies  of  exhaustion. 


8o  INFLAMMATION   AND   ITS  SEQUELAE 

Diabetes  leads  to  gangrene,  in  the  first  place,  because  it  gives  rise  to 
endarteritis,  and  consequent  diminution  in  the  calibre  of  the  vessels ; 
and  in  the  second  place,  because  the  tissues  of  the  diabetic  are  less 
able  to  resist  injury  than  healthy  ones ;  they  are  especially  sensi- 
tive to  the  pyogenic  organisms  which  appear  to  grow  in  them  with 
special  rapidity  and  virulence.  Some  authorities  also  hold  that  the 
innervation  of  the  tissues  is  interfered  with  as  the  result  of  central  nervous 
disturbance,  and  that  they  are  thus  predisposed  to  gangrene. 

Treatment. — Bearing  in  mind  the  great  tendency  of  their  tissues  to 
gangrene,  diabetics  must  be  specially  warned  to  avoid  any  injury,  how- 
ever trivial,  lest  acute  inflammation,  which  may  become  gangrenous, 
should  follow ;  more  especially  they  should  avoid  slight  injuries  to  the 
feet,  the  wearing  of  tight  boots,  etc.  Strict  asepsis  should  be  employed 
in  the  case  of  any  wound  from  which  they  may  suffer,  and  when  gangrene 
has  set  in,  the  usual  treatment  should  be  adopted,  namely,  the  disinfection 
of  the  limb  and  the  application  of  an  antiseptic  dressing  (see  p.  68). 

General. — The  patient  must  be  placed  on  anti-diabetic  diet,  that  is 
to  say,  he  should  avoid  substances  that  lead  to  the  production  of  sugar, 
such  as  sugar  itself,  all  starchy  foods,  potatoes,  etc.  The  stringency  of 
the  diet  must  depend  on  the  amount  of  sugar  in  the  urine  and  the  condi- 
tion of  the  patient ;  if  he  be  very  weak  it  is  inadvisable  to  put  him 
suddenly  on  too  strict  a  diet.  The  following  dietary,  for  which  we  are 
indebted  to  Dr.  Burney  Yeo,i  will  give  full  details  as  to  the  diet  of  a 
diabetic  patient. 

SEEGEN'S  DIETARY. 
Sanctioned. 

IN  ANY  QUANTITY — Flesh  of  all  kinds  ;  preserved  (smoked)  meats,  ham, 
tongue,  bacon ;  fish  of  all  kinds ;  oysters  and  shell-fish ;  crabs, 
lobsters ;  animal  jellies ;  aspic ;  eggs,  caviare,  cream,  butter, 
cheese ;  spinach,  cooked  salads,  endive,  cucumber,  green  asparagus, 
watercress,  sorrel,  artichokes,  mushrooms ;  nuts. 

IN  SMALL  QUANTITY — Cauliflower,  carrots,  turnip,  white  cabbage,  green 
beans ;  berries,  such  as  strawberries,  raspberries,  currants ;  also 
oranges  and  almonds. 

BEVERAGES. 

IN  ANY  QUANTITY — Water,  soda-water ;  tea,  coffee  ;  Bordeaux,  Rhine, 
and  Moselle  wines  ;  Austrian  and  Hungarian  table  wines.  In  short, 
all  wines  that  are  not  sweet,  and  that  contain  only  a  moderate 
amount  of  alcohol. 

IN  VERY  SMALL  QUANTITIES — Milk,  unsweetened  ;  almond  emulsion  ; 
brandy,  bitter  beer ;  lemonade,  unsweetened. 

1  A  Manual  of  Medical  Treatment  or  Clinical  Therapeutics  (Cassell  &  Co., 
London) 


GANGRENE  81 

Forbidden. 

Farinaceous  foods  of  all  kinds  (bread  only  in  very  small  quantity  accord- 
ing to  the  discretion  of  the  physician)  ;  sugar ;  potatoes,  rice, 
tapioca,  arrowroot,  sago,  groats ;  peas,  beans ;  sweet  fruits,  as 
grapes,  cherries,  peaches,  apricots,  plums,  and  all  kinds  of  dried 
fruits. 

BEVERAGES. 

Champagne  and  sweet  wines  and  beers,  must,  fruit  wines  and  fruit 
juices  and  syrups  ;  sweet  lemonade  ;  liqueurs  ;  ices  and  sorbets  ; 
cocoa  and  chocolate. 

Opium,  or  still  better,  codeine,  should  be  administered  in  large 
quantities.  The  codeine  is  given  in  doses  of  a  quarter  of  a  grain  three 
time  a  day,  which  is  gradually  increased  up  to  five  grains.  Stimulants 
may  also  be  necessary  if  the  pulse  is  becoming  weak,  and  the  patient 
exhausted ;  the  best  are  dry  wines,  such  as  dry  sherry  or  whisky  in 
small  quantities  ;  sweet  wines  should  be  strictly  avoided. 

Local. — Question  of  Amputation. — This  arises  at  an  early  period. 
Formerly  the  rule  was  not  to  amputate  in  diabetic  gangrene,  partly  on 
account  of  the  great  tendency  to  inflammation  and  suppuration  in  the 
stump,  leading  to  extension  of  the  gangrene,  and  partly  owing  to  the 
risk  of  death  from  diabetic  coma.  This  rule,  however,  has  been  com- 
pletely altered  by  the  introduction  of  antiseptic  measures,  and  from 
recent  work  it  seems  quite  evident  that  the  best  treatment  in  most 
cases  is  early  amputation.  If  left  alone,  the  majority  of  patients  die. 
By  strict  asepsis  inflammation  in  the  stump  is  avoided,  septic  troubles 
are  prevented,  and  an  extension  of  the  gangrene  does  not  occur  if  the 
amputation  be  performed  sufficiently  high  up.  For  example,  if  the 
gangrene  has  only  extended  to  the  foot,  the  amputation  may  be  carried 
out  at  the  seat  of  election  or  a  Lister's  amputation  in  the  lower  part  of  the 
leg  may  be  performed,  provided  that  there  be  no  marked  arterial  change 
and  no  evidence  of  pus  spreading  up  the  leg.  If  either  of  these  com- 
plications be  present,  the  amputation  should  be  performed  through  the 
condyles  of  the  femur  or  in  the  lower  third  of  the  thigh. 

The  principal  risk  is  from  diabetic  coma.  The  risk  of  this  very  fatal 
complication  is  undoubtedly  increased  to  some  extent  by  the  use  of 
an  anaesthetic,  more  especially  of  chloroform ;  for  this  reason  many 
surgeons  prefer  to  employ  spinal  anaesthesia  (see  p.  486).  On  the  other 
hand,  the  patient  is  not  really  more  liable  to  an  attack  of  diabetic 
coma  after  amputation  per  se  than  he  is  during  the  course  of  the 
gangrene.  In  any  case  the  risk  of  operation  is  not  so  great  as  the  risk 
the  patient  runs  if  left  unoperated  upon. 

Gangrene  after  Acute  Fevers. — Gangrene  from  this  cause  is  some- 
times a  sequela  of  typhoid  fever,  and  attacks  the  extremities  and 


82  INFLAMMATION  AND  ITS  SEQUELS 

the  parts  farthest  from  the  heart,  especially  the  toes,  the  nose,  the  ears,  and 
sometimes  the  fingers.  This  form  of  gangrene  is  generally  due  to  endar- 
teritis  and  thrombosis  ;  in  some  cases,  however,  it  follows  embolism.  It 
usually  begins  during  the  period  of  convalescence  and  is  of  the  dry  variety. 

Treatment. — The  treatment  is  to  disinfect  the  part,  apply  an  antiseptic 
dressing  (see  p.  68),  and,  in  the  case  of  the  extremities,  to  wait  for  a  line 
of  demarcation  before  amputating,  partly  because  the  exact  amount  of 
tissue  that  will  die  cannot  be  known,  and  partly  because  the  patient's 
condition  is  generally  so  bad  at  the  onset  of  the  gangrene  that  amputation 
would  be  very  apt  to  cause  death.  In  addition,  it  is  important  to  support 
the  patient's  strength  and  treat  any  symptoms  that  may  arise. 

Gangrene  from  Ergot. — This  form  of  gangrene  may  occur  in 
epidemics,  when  the  rye  in  certain  districts  has  become  infected  with  the 
ergot  fungus  (daviceps  purpurea)  and  when  families  eat  large  quantities 
of  this  infected  rye  in  the  form  of  rye-bread.  The  early  effect  of  ergot 
is  to  produce  tonic  contraction  of  the  smaller  blood-vessels,  and  if  this 
be  kept  up  for  a  long  tune,  it  may  lead  to  gangrene,  more  especially 
of  the  extremities. 

Certain  symptoms,  such  as  diarrhoea,  buzzing  hi  the  ears,  cramps,  cold- 
ness of  the  extremities,  etc.,  precede  the  occurrence  of  gangrene.  The 
affection  usually  attacks  men  between  thirty  and  forty  years  of  age. 
The  form  of  gangrene  is  usually  dry,  but  in  certain  cases  it  may  be  moist, 
and  it  may  vary  in  extent  from  the  loss  of  a  nail  to  the  loss  of  a  limb. 

Treatment. — In  the  first  instance  the  cause  should  be  removed.  If 
there  be  the  premonitory  symptoms  of  ergot  poisoning,  or  the  epidemic 
occurrence  of  gangrene  in  young  patients  who  are  otherwise  healthy,  the 
food  must  be  examined,  and  if  the  claviceps  be  present,  untainted  bread 
must  be  substituted.  Great  attention  should  be  paid  to  the  nutrition  of 
the  patient,  and  the  use  of  strong  coffee  is  highly  recommended  as  an 
antidote. 

When  gangrene  has  set  in,  the  patient  must  be  kept  in  bed,  and 
the  part  disinfected  and  kept  aseptic  and  dry ;  before  deciding  on 
amputation,  a  line  of  demarcation  should  be  waited  for,  because  it  is 
impossible  to  say  how  much  of  the  tissue  will  die.  As  a  rule,  the  line 
of  demarcation  is  permanent  when  it  has  once  formed,  and  therefore,  the 
best  method  of  fashioning  the  flaps  can  be  decided  upon  and  amputation 
performed  without  any  further  delay  as  soon  as  it  is  well-marked. 

INFECTIVE     GANGRENE. 

The  third  great  group  of  gangrene  is  that  due  to  specific  infective 
organisms.  In  former  days,  a  variety  of  gangrenous  processes  attacked 
wounds  as  the  result  of  sepsis,  but  they  are  seldom  seen  now.  It 
will  be  sufficient  if  we  speak  here  of  three  forms  of  specific  gangrene, 
namely :  (i)  acute  traumatic  gangrene  ;  (2)  phagedena ;  and  (3)  cancrum 
oris  or  noma. 


GANGRENE  83 

Acute  Traumatic  Gangrene. — This  is  a  form  that  attacks  wounds 
and  is  due  to  the  growth  of  bacteria  in  the  tissues  ;  it  especially  attacks 
wounds  which  have  been  soiled  with  earth.  The  emphysematous  form  of 
the  affection  is  probably  most  often  due  to  the  presence  of  a  gas-producing 
organism,  the  bacillus  aerogenes  capsulatus,  but  the  bacillus  of  malignant 
oedema  may  produce  similar  symptoms  without  much  gas  in  the  tissues  ; 
there  are  probably  other  organisms  also  concerned  in  some  of  these 
cases.  The  disease  usually  begins  about  the  second  or  third  day  after  the 
accident.  As  a  rule,  its  course  is  very  rapid,  averaging  about  three  days 
before  the  death  of  the  patient ;  the  part  becomes  greatly  swollen  and 
cedematous  and  generally  crepitates  from  the  presence  of  enormous 
quantities  of  gas  developed  in  the  tissues.  The  constitutional  symptoms 
are  always  severe,  the  temperature  is  usually  high,  the  pulse  rapid 
and  ultimately  irregular.  In  addition  to  this  there  is  great  prostration, 
the  patient's  condition  passing  rapidly  into  the  '  typhoid  state.' 

Treatment. — The  first  point  in  the  treatment  is  prophylaxis.  When 
wounds  are  soiled  with  earth  or  dirt,  especial  care  should  be  taken  to  dis- 
infect them,  and  the  best  plan  is  to  place  the  patient  under  an  anaesthetic, 
to  scrub  out  the  earth  with  a  nail  brush  and  '  strong  mixture '  (see  p.  50), 
and  then  to  apply  undiluted  carbolic  acid  to  the  whole  surface  of  the 
wound.  It  must  be  remembered  that  acute  traumatic  gangrene  is  not 
the  only  disease  which  results  from  the  soiling  of  wounds  with  earth, 
malignant  oedema  and  tetanus  being  often  produced  in  a  similar  manner. 
Hence  thorough  disinfection  of  such  wounds  is  imperative. 

Local  Treatment. — In  acute  traumatic  gangrene  of  the  extremities, 
amputation  at  the  highest  possible  point  offers  the  only  chance  of  saving 
the  patient.  Almost  all  the  patients  attacked  by  this  affection  die,  and 
unfortunately  even  after  amputation  only  about  5  per  cent,  recover, 
because  it  is  extremely  difficult  and  often  impossible  to  get  above  the 
disease  except  at  a  very  early  stage.  In  amputating,  the  greatest  care 
must  be  taken  to  disinfect  the  skin,  and  especially  to  avoid  soiling  the 
amputation  wound  with  the  discharge  from  the  gangrenous  part.  Hence, 
in  addition  to  the  ordinary  disinfection  of  the  skin  at  the  seat  of  ampu- 
tation, the  gangrenous  extremity  should  be  wrapped  up  in  antiseptic 
gauze  wrung  out  of  the  strong  mixture,  and  then  enveloped  in  sterilised 
jaconet  or  mackintosh  firmly  fastened  round  the  limb,  well  above  the  upper 
limit  of  the  gangrene,  so  that  none  of  the  contents  of  the  bullae,  etc.,  can 
run  out.  This  is  done  by  an  assistant  who  is  not  afterwards  allowed  to 
take  any  part  in  the  operation.  In  operating  on  these  cases  the  use  of 
all  other  measures  employed  in  the  prevention  of  shock  (see  Chap.  VI.) 
will  probably  be  called  for.  In  these  cases,  too,  it  is  important  to  avoid 
the  use  of  a  general  anaesthetic,  and  spinal  anaesthesia  (see  p.  486)  finds  a 
very  useful  application. 

After  the  operation,  the  flaps  should  be  left  open,  two  or  three  loose 
stitches  at  most  being  inserted.  If  the  patient  survive,  the  wound  can 

G2 


84  INFLAMMATION  AND   ITS  SEQUELS 

be  sewn  up  as  soon  as  the  flaps  have  granulated  and  it  is  evident  that  the 
specific  infection  has  been  removed,  or  its  effects  are  at  an  end. 

In  some  situations,  the  highest  amputations  that  can  be  performed, 
that  is  to  say  at  the  shoulder  or  hip  joint,  may  still  leave  tissues  either 
certainly,  or  probably,  infected,  and  in  these  cases  free  incisions  must 
be  made  into  the  infected  area  beyond  the  line  of  amputation  in  the 
manner  recommended  for  the  treatment  of  cellulitis.  For  example, 
after  an  amputation  through  the  shoulder  joint,  the  tissues  of  the  chest 
wall  or  even  the  flaps  may  need  to  be  freely  incised  and  in  some  cases 
this  has  proved  successful. 

Phag'edena. — Phagedena  is  a  disease  practically  never  seen  nowadays, 
but  was  formerly  very  common,  especially  in  times  of  war.  It  is  undoubtedly 
a  parasitic  affection,  but  the  exact  nature  of  the  organism  is  unknown. 
It  consists  essentially  in  the  production  on  the  wound  of  a  pseudo- 
membranous  material,  beneath  which  the  tissues  ulcerate  or  become 
gangrenous,  and  two  forms,  namely,  an  ulcerative  and  a  gangrenous  one, 
are  usually  described.  In  the  ulcerative  form  a  pulpy  membrane  appears 
on  the  surface  of  the  wound  ;  beneath  this,  cup-like  losses  of  substance 
occur,  and  subsequently  rapid  ulceration  takes  place  along  the  planes  of 
the  tissues.  In  the  other  form,  the  wound  becomes  covered  with  a  thicker 
membrane,  which  is  dark  coloured,  very  pulpy,  extending  rapidly,  leading 
to  sloughing  of  the  skin  and  muscles,  and  not  uncommonly  attacking  the 
vessels  and  giving  rise  to  severe  haemorrhage.  The  disease  spreads  with 
great  rapidity,  and  the  patient  usually  dies  in  from  twenty-four  to  forty- 
eight  hours. 

Treatment. — The  prophylactic  treatment  consists  of  strict  antiseptic 
precautions  in  cases  of  all  wounds,  isolation  of  the  affected  individual,  and 
great  care  not  to  infect  other  persons  with  the  instruments,  or  by  the 
attendants.  Rubber  gloves  must  always  be  worn  by  everyone  who  has 
to  deal  with  the  dressings  in  these  cases. 

In  the  local  treatment  the  chief  reliance  is  placed  on  destruction  of 
the  pulpy  material,  either  by  the  application  of  the  actual  cautery,  or  by 
the  use  of  nitric  acid  (see  p.  85)  or  the  liquor  ferri  perchloridi ;  of  these 
the  actual  cautery  seems  to  be  the  most  efficacious.  The  parts  are 
thoroughly  destroyed  with  the  cautery  at  white  heat,  wherever  there  is 
the  slightest  suspicion  of  the  presence  of  the  membranous  material. 
The  wound  is  then  packed  with  boric  lint  dipped  in  I  to  5  carbolic  oil.  If 
perchloride  of  iron  be  used,  the  wound  should  be  first  dried,  and  then  lint 
soaked  in  the  perchloride  is  packed  into  it  and  left  for  four-and-twenty 
hours,  after  which  it  may  be  dressed  with  boric  lint  and  carbolic  oil.  The 
perchloride  of  iron  has  not  a  very  powerful  effect  in  this  disease,  and 
should  only  be  employed  when  it  is  slight  in  extent  and  is  not  spreading 
rapidly.  If  the  part  affected  be  an  extremity,  amputation  should  be 
performed,  provided  it  be  possible  to  get  well  above  the  disease.  Natur- 
ally, great  care  must  be  taken  not  to  infect  the  stump. 


GANGRENE  85 

The  general  condition  of  the  patient  needs  the  most  careful  attention. 
Stimulants,  strychnine  and  tonics  should  be  freely  administered,  and 
every  effort  made  to  maintain  the  patient's  strength. 

Cancrum  Oris. — Cancrum  oris  is  a  disease  affecting  children,  and 
beginning  in  the  mouth  or  the  vulva  (when  it  is  termed  'noma').  It 
generally  attacks  weakly  children  of  from  two  to  five  years  of  age,  who 
are  convalescing  from  some  other  affection,  such  as  measles  or  scar- 
latina. In  the  mouth,  it  usually  begins  in  the  gums  ;  the  patient  com- 
plains of  pain,  the  breath  becomes  foetid,  and  there  is  increased  flow  of 
saliva.  Ulceration  then  occurs  about  the  gums,  a  black  spot  appears 
inside  the  cheek,  and  this  extends  through  the  cheek ;  a  slough  forms, 
and  large  portions  of  the  jaw  and  cheek  may  be  destroyed.  The  patient's 
general  condition  is  very  serious,  the  temperature  is  high,  and  death 
usually  occurs  in  from  three  to  four  days.  The  disease  is  due  to  long 
delicate  bacilli  which  are  found  in  large  numbers  in  the  slough,  and  more 
especially  in  the  living  tissues  just  beyond  it. 

Treatment. — This  aims  at  destroying  all  the  affected  parts,  and  the 
portions  of  the  living  tissues  around  in  which  the  bacilli  are  present.  All 
the  parts  which  are  gangrenous  must  be  clipped  away  ;  not  only  the  soft 
parts,  but  the  portion  of  the  jaw  affected  must  be  removed,  and  this 
should  be  done  till  a  surface  is  exposed  which  bleeds  everywhere.  Pres- 
sure is  applied  to  arrest  the  bleeding,  and  then  strong  nitric  acid  is  painted 
over  or  rubbed  into  the  raw  surface  with  a  stout  glass  rod  or  a  glass 
brush.  The  acid  is  allowed  to  act  for  about  ten  minutes,  several  fresh 
applications  being  repeated  during  that  time.  When  the  surgeon  is 
satisfied  that  every  portion  of  the  disease  has  been  thoroughly  destroyed, 
the  action  of  the  acid  is  arrested  by  pouring  over  it  a  saturated  solution 
of  carbonate  of  soda  until  the  acid  is  completely  neutralised.  This  may 
be  presumed  when  bubbles  of  carbonic  acid  gas  cease  to  form.  Any- 
thing short  of  this  treatment  will  fail  in  arresting  the  disease.  To  leave 
the  sloughs  on  the  surface  and  to  apply  antiseptic  washes  or  strong 
antiseptics  to  them  is  absolutely  useless,  for  the  regions  in  which  the 
organisms  are  growing  are  the  living  tissues  just  beyond  the  parts  actually 
dead,  and  these  cannot  be  reached  unless  the  sloughs  be  removed  first. 

After  the  acid  has  been  neutralised,  the  part  should  be  powdered  with 
iodoform,  and  full-strength  boric  ointment  spread  on  butter-cloth  applied 
with  boric  lint  outside  it.  The  mouth  (or  vagina,  in  the  case  of  noma) 
should  be  washed  out  with  sanitas  and  water  (about  I  part  in  12) 
several  times  a  day.  The  wound  will  begin  to  granulate  in  five  or 
six  days,  and  then  the  half-strength  boric  ointment  may  be  substi- 
tuted. Stimulants  are  necessary,  and  also  nourishing  diet,  and  probably 
strychnine  will  be  required  at  first.  Great  deformities  are  left  after 
this  disease,  especially  in  the  cheek,  but  the  treatment  of  these  is  dealt 
with  in  connection  with  the  plastic  surgery  of  the  face  and  jaw. 

In  addition  to  the  specific  form,  two  other  types  of  gangrene  occur  in 


86  INFLAMMATION  AND  ITS  SEQUELS 

the  mouth.  In  children  there  may  be  severe  stomatitis  leading  to  actual 
gangrene  of  portions  of  the  mucous  membrane  of  the  gum.  In  these 
cases  there  is  great  swelling  of  the  tongue  and  cheek,  large  areas  of  which 
are  covered  with  a  foul  whitish  membrane.  The  breath  is  very  offensive ; 
there  is  profuse  salivation  and  the  patient  is  often  extremely  ill  for  a 
time ;  the  temperature  does  not  run  so  high  as  in  true  cancrum  oris,  and 
the  disease  tends  to  run  a  more  benign  course.  No  specific  organisms  can 
be  found  in  this  condition,  which  is  not  sharply  marked  off  from  ordinary 
acute  stomatitis.  The  best  treatment  for  these  cases  is  a  mouth-wash 
containing  resorcin.  A  good  formula  is  the  following : — 

R  Resorcini gr.  xxx 

Potass.  Chloratis        .        .         .     gr,  x 

Glycerin!  boracis        .         .        ad  §  j 
Misce. 

The  mouth  should  be  frequently  cleansed  with  weak  sanitas  (i  in  10) 
or  peroxide  of  hydrogen  (10  vols.),  and  the  above  solution  should  be 
painted  all  over  the  affected  area.  A  brisk  calomel  purge  should  be 
given,  and  the  child  put  under  the  best  hygienic  surroundings  obtainable. 
A  mixture  containing  chlorate  of  potash  and  cinchona  bark  may  be 
given  internally.  When  the  disease  has  become  quiescent,  the  condition 
of  the  mouth  should  be  carefully  looked  to,  and  any  decayed  teeth 
removed  or  filled. 

The  free  administration  of  mercury  may  also  lead  to  severe  gan- 
grenous stomatitis,  especially  when  the  mouth  has  been  allowed  to 
remain  in  a  septic  and  neglected  condition.  With  the  smaller  doses  of 
mercury  now  in  vogue  this  condition  is  uncommon. 

The  treatment  consists  in  stopping  the  administration  of  mercury 
and  employing  a  mouth-wash  containing  chlorate  of  potash. 


DIVISION    II. 
WOUNDS  AND  THEIR  COMPLICATIONS. 

CHAPTER  V. 

WOUNDS. 

WOUNDS  may  be  the  result  of  accident  or  may  be  made  intentionally 
by  the  surgeon.  They  may  be  divided  into  incised,  contused,  lacer- 
rated,  gunshot,  or  poisoned  wounds,  and  those  caused  by  heat  and  cold. 
Before  proceeding  to  deal  with  them,  however,  it  seems  advisable  to  say 
a  few  words  about  the  general  management  of  operations. 

OPERATIONS  AND  THEIR  MANAGEMENT. 

Operations  may  be  divided  into  two  great  classes,  namely,  those  in 
which  the  condition  is  urgent  and  the  operation  must  be  carried  out 
without  delay,  and  those  in  which  some  time  may  be  allowed  to  elapse 
after  an  operation  has  been  decided  upon.  In  the  latter  case  various 
preliminary  steps  should  be  taken,  some  of  which  we  shall  indicate. 

PREPARATION   OF  THE   PATIENT  FOR   OPERATION. 

Certain  points  in  the  preparation  of  the  patient  are  peculiar  to 
operations  in  certain  regions,  and  will  be  mentioned  in  describing  those 
operations  ;  such,  for  example,  are  the  cleansing  of  the  mouth  and 
teeth  before  operations  on  the  tongue  and  mouth,  washing  out  the 
stomach  before  gastrostomy  and  gastro-enterostomy,  emptying  the  lower 
bowel  before  excision  of  the  rectum,  and  so  on.  But,  apart  from 
these,  there  are  certain  points  common  to  many  operations  which  require 
consideration  here. 

87 


88  WOUNDS 

The  mental  attitude  of  the  patient  is  of  considerable  importance, 
especially  as  affecting  the  occurrence  of  shock  during  and  after  the  opera- 
tion. When  he  has  once  decided  to  undergo  an  operation,  the  patient 
should  be  encouraged  to  look  forward  to  a  successful  result ;  nothing  is 
worse  for  him  than  to  feel  that  he  is  going  to  succumb  ;  shock  certainly 
seems  to  intervene  more  quickly  and  more  powerfully  under  such  circum- 
stances. Hence,  although  the  patient  and  his  friends  should  be  made 
aware  of  the  real  danger  and  results  of  the  proposed  operation,  the 
brightest  side  of  the  picture  should  be  put  in  the  foreground  as  soon  as 
its  performance  has  been  decided  on,  and  any  drawbacks  should  be  made 
light  of. 

There  is  no  object  in  interfering  with  the  patient's  usual  diet  on  the 
preceding  day,  but  it  is  well  that  the  evening  meal  should  be  light  and 
easily  digestible.  When  a  general  anaesthetic  is  to  be  given,  food  should 
not  be  given  by  the  mouth  later  than  three  hours  before  the  operation, 
and  if  the  latter  is  to  be  performed  in  the  early  morning  it  is  not  worth 
while  waking  up  the  patient  for  a  meal.  If  he  be  awake,  he  may  have 
a  cup  of  strong  hot  beef-tea  or  meat  juice  about  six  o'clock  in  the  morning 
when  the  operation  is  to  be  performed  about  nine  When  the  operation  is 
to  be  a  severe  one,  it  is  also  advisable  to  give  a  nutrient  enema  half  an 
hour  before  the  operation. 

The  bowels  should  be  well  cleared  out  in  all  cases  before  the  opera- 
tion, and  the  most  satisfactory  aperient  is  castor  oil ;  about  an  ounce 
should  be  administered  overnight,  followed  by  a  plain  water  or  soap-and- 
water  enema  in  the  morning.  The  latter  is  made  by  rubbing  up  Castile 
soap  in  warm  water  until  a  pretty  thick  lather  is  formed,  and  about  a  pint 
is  injected.  When  the  patient  cannot  take  castor  oil,  or  when  it  causes 
much  griping,  a  teaspoonful  of  compound  liquorice  powder  at  night, 
followed  by  an  enema  in  the  morning,  will  generally  suffice.  The  chief 
reason  for  clearing  out  the  bowels,  even  though  they  may  have  been  acting 
regularly  beforehand,  is  that  the  patient  is  generally  constipated  after  an 
operation  and  his  digestion  is  disordered ;  and,  further,  it  is  important 
to  get  rid  of  material  which  may  cause  trouble  by  decomposing,  the  septic 
products  being  absorbed  and  diminishing  the  patient's  vitality.  The 
evacuation  of  the  bowels  is  also  of  importance  in  certain  operations — for 
example,  in  piles — where  steps  are  taken  after  the  operation  to  delay  their 
action  for  some  time.  While,  as  a  general  rule,  the  aperient  should  be 
given  on  the  night  preceding  the  operation,  in  some  cases  it  is  better  to  give 
it  twenty-four  hours  earlier,  and  at  most  a  simple  enema  on  the  morning 
of  the  operation.  This  is  the  case  in  rectal  operations  and  in  a  good  many 
abdominal  sections,  such  as  appendicectomy.  If  the  aperient  be  given  a 
few  hours  before,  the  bowels  are  apt  to  be  in  an  irritable  state  after  the 
operation  and  much  trouble  from  griping  pains  and  flatulence  may  result. 

The  most  favourable  time  for  an  operation  is  the  early  morning, 
and  that  for  two  reasons.  In  the  first  place  the  patient,  especially  if  he 


OPERATIONS  AND  THEIR  MANAGEMENT  89 

has  passed  a  good  night,  has  not  so  long  to  worry  and  excite  himself 
about  the  operation  as  when  a  later  hour  is  chosen  ;  and,  in  the  second 
place,  he  does  not  miss  his  food.  It  is  very  important  to  secure  a  good 
night's  rest  before  the  operation,  particularly  in  nervous  patients,  and 
in  most  cases  there  is  no  objection  to  the  administration  of  a  narcotic, 
preferably  a  quarter  of  a  grain  of  morphine,  subcutaneously  at  bedtime. 

THE   OPERATING   ROOM   AND   ITS  ACCESSORIES. 

In  hospitals  and  other  large  institutions,  surgical  operations  are 
usually  performed  in  operating  theatres  or  other  rooms  specially  set  apart 
for  the  purpose.  Although  there  are  at  present  many  nursing  homes 
and  private  hospitals  which  possess  operating  theatres,  by  far  the  larger 
number  of  operations  performed  in  private  are  done  in  the  patient's  own 
bedroom.  At  first  sight  it  might  seem  as  if  this  were  exposing  the  patient 
to  an  unnecessary  risk,  but  it  is  by  no  means  necessarily  the  case.  The 
elaborate  arrangements  of  a  large  operating  theatre  are  designed  not  so 
much  for  the  performance  of  any  single  operation,  as  to  enable  a  number 
of  operations  to  be  performed  in  safety  and  convenience  one  after  the 
other ;  and,  provided  that  a  sufficiently  large  and  light  room  can  be 
obtained,  where  the  heating  arrangements  are  satisfactory,  an  operation 
can  be  performed  in  perfect  safety  in  an  ordinary  private  house,  but  it 
is  well  to  reproduce  as  far  as  possible  the  conditions  of  an  operating 
theatre.  There  is  a  tendency  nowadays  for  operating  theatres  to  become 
complex,  but  the  essentials  of  an  operating  room  are  in  reality  very 
simple.  It  should  be  light,  warm,  and  readily  cleaned. 

The  best  light  is  that  known  technically  as  a  studio  light,  preferably 
with  a  north  aspect.  This  form  of  window  consists  of  two  parts,  a  large 
vertical  portion  which  should  take  up  the  greater  part  of  one  side  of  the 
theatre  and  a  sort  of  half  skylight  continued  for  two  or  three  feet  into 
the  roof  of  the  theatre.  This  provides  a  top  light  without  the  disadvan- 
tages of  a  skylight.  A  skylight  should  not  be  used,  as  it  is  apt  to  condense 
the  moisture  in  the  room  and  to  allow  this  to  drip  on  to  the  operating 
table  or  even  into  the  wound.  A  good  artificial  light  should  also  be 
installed,  if  possible  from  more  than  one  source,  so  as  to  minimise  the 
risk  of  its  failing  during  the  course  of  an  operation.  The  lights  must  be 
arranged  so  as  to  give  a  brilliant  diffuse  illumination  with  no  shadows. 

The  theatre  should  be  provided  with  some  heating  apparatus  other  than 
an  open  fire;  when  this  is  not  possible,  an  open  fire  must  be  used,  but 
it  has  many  disadvantages.  While  it  certainly  facilitates  ventilation,  its 
presence  in  a  room  where  chloroform  is  being  evaporated  leads  to  the  for- 
mation of  oxidation  products,  which  are  intensely  irritating  not  only  to  the 
patient  but  to  the  surgeon,  and  an  operation  cannot  be  conducted  properly 
under  such  conditions.  A  gas  fire  should  never  be  allowed,  as  these 
troubles  are  even  more  liable  to  occur  with  it.  If  steam  or  hot  water 


9o 


WOUNDS 


heating  cannot  be  obtained,  a  coal  fire  in  an  open  grate  should  be  employed. 
When  ether  is  being  used  there  is  a  small  additional  risk  of  fire.  The 
temperature  of  the  theatre  should  never  be  lower  than  65°  F.  during  an 
operation,  but  for  severe  cases,  especially  abdominal  sections  when  a 
considerable  amount  of  shock  is  expected,  the  temperature  should  be  even 
higher ;  indeed,  a  temperature  of  75°  to  80°  is  often  desirable.  The  effect 
of  temperature  upon  shock  is  well  known,  but  it  is  not  as  widely  appre- 
ciated as  it  deserves  to  be.  Under  an  anaesthetic  the  heat  regulating 
mechanism  is  completely  in  abeyance,  and  a  patient  exposed  to  cold 
loses  heat  much  as  he  would  do  after  death. 

The  walls  of  the  theatre  should  be  of  some  easily  washable  material, 
and  although  a  large  number  of  cements,  tilings  and  other  wall-coverings 
have  been  introduced,  there  is  perhaps  no  substance  more  suitable  for 
covering  the  walls  of  an  operating  theatre  than  a  good  enamel  paint  which 
can  be  renewed  cheaply  and  has  neither  cracks  nor  joints.  The  floor 
must  be  of  some  substance  impervious  to  wet ;  and  that  form  of  mosaic 
known  as  'terrazzo'  forms  one  of  the  best  materials.  At  the  junction  of 
the  walls  with  each  other,  and  with  the  floor  and  ceiling,  there  must  be  no 
angles  which  would  be  liable  to  harbour  dust  and  dirt  and  make  the 
cleaning  of  the  theatre  difficult ;  all  angles,  therefore,  should  be  carefully 
rounded  off.  Where  pipes  run  along  the  theatre  walls,  they  must  be  fixed 
far  enough  away  from  the  wall  to  allow  thorough  cleaning  behind  them  ; 
a  better  plan  is  to  keep  all  pipes  out  of  the  operating  theatre  proper.  In  a 
well-constructed  theatre  it  should  be  possible  to  play  a  hose  over  the 
whole  of  it  without  spoiling  any  of  its  fittings.  The  floor  should  slope 
slightly  down  to  one  side  or  to  one  corner,  where  an  open  gully  should 
conduct  off  the  waste  water  into  the  open  air. 

If  possible,  all  instrument  cases,  sterilisers,  and  other  fixtures  should 
be  kept  outside  the  theatre  itself  in  order  to  facilitate  the  cleaning  of  the 
latter.  The  fixtures  in  the  operating  theatre  should  be  reduced  to  a 
minimum,  nothing  beyond  the  instruments  and  apparatus  in  actual  use 
being  in  the  theatre  during  an  operation.  During  an  operation  people 
must  not  come  in  and  out.  All  doors  and  windows  should  be  kept 
closed,  and  the  air  supplied  to  the  theatre  should  be  passed  or  drawn 
through  a  thick  mass  of  cotton  wool  or  some  other  form  of  efficient 
filter. 

Connected  with  an  operating  theatre  of  this  kind  there  should  be 
a  series  of  rooms  in  which  the  various  preparations  connected  with  the 
operation  can  be  carried  on ;  for  instance,  a  room  in  which  the  surgeon 
can  wash  his  hands,  an  instrument  and  a  splint  room,  a  room  for 
the  sterilising  of  dressings  and  instruments,  and  an  anaesthetising  room 
are  all  of  great  importance.  In  addition,  a  recovery  room  is  extremely 
valuable  for  the  detention  of  patients  after  severe  operations.  This 
obviates  any  risk  of  exposure  during  the  passage  of  the  patient  from  the 
theatre  to  the  ward. 


OPERATIONS  AND  THEIR  MANAGEMENT  91 

The  operating  table  may  be  one  of  the  many  excellent  varieties 
supplied  by  the  instrument  makers,  but  the  essential  points  are,  that  it 
shall  be  simple  in  construction,  that  it  shall  be  capable  of  being  heated 
either  by  a  water-tank  underneath,  by  a  series  of  hot  bottles  or  radiant 
electric  heaters,  and  that  it  shall  be  possible  to  obtain  with  it  the  Tren- 
delenburg  position.  It  is  also  advisable  for  the  table  to  be  provided 
with  a  mechanism  by  which  it  can  be  raised  or  lowered.  Tables  for 
instruments,  bowls  of  lotion,  and  other  articles  required  for  the  operation 
must  be  provided. 

In  an  ordinary  dwelling  house,  of  course,  all  these  conditions  cannot 
be  complied  with,  but  a  room  can  be  easily  cleaned  sufficiently  for  the 
the  purpose,  without  any  undue  disturbance  of  the  domestic  arrange- 
ments. If  possible,  the  room  should  be  prepared  on  the  day  before  the 
operation,  all  pictures,  furniture,  etc.,  being  removed,  and  should  not 
be  disturbed  afterwards. 

When,  however,  an  operation  has  to  be  performed  as  a  matter  of 
urgency,  it  is  important  not  to  disturb  anything  that  is  in  the  room  more 
than  is  absolutely  necessary ;  the  removal  of  furniture,  pictures,  or 
carpets  is  accompanied  by  a  stirring-up  of  the  dust  lying  upon  them, 
and  in  an  emergency  it  is  better  to  leave  things  of  this  nature  in  their 
original  position,  and  cover  over  everything  with  clean  dust  sheets. 
Operating  tables,  basins,  and  other  appliances  can  be  hired  from  the 
surgical  instrument  makers,  and  when  feasible,  this  should  be  done; 
when  this  is  impossible,  they  must  be  extemporised.  Two  long  dressing 
tables  placed  together,  so  as  to  form  a  T,  make  a  very  good  operating 
table.  The  patient  lies  upon  the  one  forming  the  vertical  limb  of 
the  T  with  his  head  and  shoulders  resting  upon  the  transverse  one.  The 
table  should  be  covered  by  a  folded  blanket,  over  which  is  placed  a 
sheet,  which  in  its  turn  is  covered  by  a  mackintosh  opposite  the  area 
of  the  operation  ;  the  whole  table  should  not  be  covered.  A  number 
of  bowls  must  be  collected  and,  if  possible,  these  should  be  boiled 
in  a  copper  or  large  fish  kettle.  If  a  suitable  vessel  for  boiling  bowls 
cannot  be  obtained,  they  must  be  washed  in  a  i  in  20  carbolic  or  a  I  in  500 
sublimate  solution.  One  or  more  small  tables  should  be  covered  by 
mackintoshes,  upon  which  are  placed  boiled  towels  wrung  out  of  I  in  20 
carbolic  or  i  in  2000  sublimate  lotion ;  these  serve  to  hold  the  bowls, 
instruments,  and  appliances  during  the  operation. 

Important  as  the  operating  theatre  is,  it  must  not  be  forgotten  that 
a  very  small  percentage  of  the  cases  which  suppurate  do  so  because  of 
the  bad  surroundings  under  which  the  operation  is  undertaken  ;  indeed, 
operations  can  be  and  are  performed  with  safety,  or  at  least  with  a 
minimum  risk,  in  badly  constructed  operating  theatres  or  in  the  dirtiest 
of  houses.  The  majority  of  suppurative  cases  originate  from  the  intro- 
duction of  organisms  from  the  surgeon's  hands,  from  ligatures,  sponges 
or  swabs,  or  from  imperfect  lotions  and  dressings. 


92 


WOUNDS 


INSTRUMENTS,    LIGATURE  MATERIALS   AND   DRESSINGS,   AND 
THEIR  STERILISATION. 

Two  main  methods  are  used  for  the  sterilisation  of  ligatures  and  dress- 
ings, viz.,  by  means  of  heat  and  by  means  of  chemical 
solutions. 

Instruments  are  usually  sterilised  by  boiling  ; 
they  should  be  placed  in  a  one-per-cent.  solution  of 
ordinary  washing  soda,  which  is  already  boiling.  If 
the  instruments  be  placed  in  this  solution  before  it 
is  boiled  and  then  be  brought  to  the  boil,  a  deposit 
of  lime  salts  takes  place  and  the  instruments  are 
covered  with  a  fine  white  powder,  and  are  also 
liable  to  rust.  All  instruments  should  be  boiled 
for  at  least  fifteen  minutes,  but  it  is  well  to  boil 
them  longer  if  time  permits.  Many  organisms  are 
killed  almost  instantaneously  by  boiling,  but  there 
are  others  which  are  more  resistant,  and  for  safety  it 
is  necessary  to  continue  the  boiling  for  at  least  the 
specified  time.  When  boiled,  we  are  in  the  habit  of 
placing  the  instruments  in  a  wide  flat  dish,  covering 
them  with  a  i  in  20  or  a  I  in  40  solution  of  carbolic 
acid  ;  this  is  done  because,  although  they  have  been 
sterilised,  they  are  none  the  less  liable  to  be  infected 
by  dust  or  by  contact  with  other  articles,  and  this 
risk  is  prevented,  or  its  evil  effects  are  entirely 
avoided,  by  keeping  them  in  an  antiseptic  solution. 
Knives,  scissors,  and  needles  are  injured  by  boiling, 
chiefly  on  account  of  the  large  amount  of  carbonic 
acid  in  the  water  and  the  deposit  of  lime  salts  along 
their  edges.  Knives  and  other  sharp  instruments  can 
be  boiled  without  deterioration  in  distilled  water 
but,  as  this  is  not  always  available  in  large  quanti- 
ties, it  is  usually  sufficient  to  disinfect  them  by 
immersing  them  for  a  few  minutes  in  undiluted  car- 
bolic acid,  which  is  afterwards  washed  off  in  boiling 
water  ;  they  are  then  placed  in  the  instrument  trays 
containing  the  carbolic  solution. 

Instruments  which  are  injured  by  boiling  or  by  prolonged  soaking  in 
antiseptic  solution,  for  example,  gum  elastic  catheters,  may  be  sterilised 
by  keeping  them  in  a  jar  at  the  bottom  of  which  is  placed  '  trioxymethy- 
lene,'  a  substance  which  slowly  gives  off  formalin  vapour  at  atmospheric 
temperature ;  this  is  a  perfectly  efficient  method  of  sterilising,  but  it 
takes  several  hours,  and  the  formalin  vapour  must  be  of  considerable 


FIG.  23. — GLASS  JAR 
FOR  THE  STERILISATION 
OF  CATHETERS. — This  is 
also  useful  for  other  in- 
struments which  can 
neither  be  boiled  nor  im- 
mersed in  an  antiseptic 
solution.  The  catheters 
are  suspended  by  a  per- 
forated metal  plate 
which  forms  a  catheter 
gauge ;  this  rests  upon 
a  shoulder  at  the  upper 
end  of  the  vessel,  the 
bottom  of  "which  is 
covered  with  a  layer  of 
formalin  or  '  Paraform  ' 
tablets.  The  jar  has  a 
tight  fitting  cover,  so  as 
to  prevent  escape  of  the 
formalin  vapour. 


OPERATIONS  AND  THEIR  MANAGEMENT  93 

strength.  If  the  air  in  the  top  of  a  jar  containing  the  trioxymethylene 
can  be  inhaled  without  discomfort,  it  can  be  assumed  safely  that  its 
sterilising  power  is  not  very  great.  The  lid  of  the  jar  should  fit  tightly  ; 
for  catheters  the  best  form  is  an  upright  cylinder  with  a  tightly  fitting 
ground-glass  stopper  and  a  perforated  rack  for  the  catheters  to  hang  in. 

Catgut. — The  best  material  for  and  sterilisation  of  ligatures  has  aroused 
considerable  controversy.  We  have  been  in  the  habit  of  using  catgut, 
a  substance  which  has  received  much  undeserved  condemnation,  especially 
in  this  country  ;  we  have  used  it,  however,  for  many  years  with  com- 
plete satisfaction  and  with  no  bad  results.  Catgut  is  prepared  from 
sheep's  intestines  and,  as  originally  obtained,  is  doubtless  teeming  with 
bacteria.  The  first  stage  in  its  preparation  is  treatment  with  sulphurous 
and  chromic  acids  l ;  this  produces  a  tough  greenish  or  greenish-yellow 
thread  which  will  last  in  the  body  for  a  considerable  time,  usually  about 
a  month  or  six  weeks. 

This  sulpho-chromic  catgut  is  sterilised  with  certainty  by  immersing 
it  in  a  i  in  20  solution  of  carbolic  acid  for  at  least  a  fortnight,  the  solution 
being  changed  repeatedly  and  kept  tightly  stoppered.  If  more  rapid 
preparation  be  required,  the  catgut  is  wound  loosely  round  a  bobbin 
and  immersed  for  about  twelve  hours  in  undiluted  carbolic  acid  ;  this 
causes  the  thread  to  become  transparent  much  as  does  a  microscopic 
specimen  cleared  by  xylol  or  clove  oil.  It  is  then  immersed  in  a  I  in  20 
carbolic  solution  when  it  once  more  becomes  opaque,  regains  much  of  its 
strength,  and  forms  an  efficient  material  for  ligatures  and  sutures.  Cat- 
gut prepared  in  this  way  can  be  kept  unimpaired  in  a  I  in  20  carbolic 

1  See  Lister's  method  of  chromicising  catgut:  Lancet,  February  5,  1881.  The 
directions  are  as  follows  : — 

The  preparing  liquid  must  be  twenty  times  the  weight  of  the  catgut,  so  for 
40  gr.  of  catgut  800  gr.  of  preparing  liquid  are  required.  It  is  made  by  mixing 
two  liquids,  viz.,  the  chromium  sulphate  liquid  and  the  sublimate  liquid.  The 
sublimate  liquid  is  : 

Corrosive  sublimate    .         .         .     gr.      2 
Distilled  water    .         .         .         .     gr.  320 

The  sublimate  may  be  dissolved  by  heat,  but  the  solution  must  be  used  cold.  The 
chromium  sulphate  liquid  is  prepared  thus : 

Chromic  acid       .         .         .         .     gr.      4 
Distilled  water    .         .         .         .     gr.  240 

Add  to  this  as  much  sulphurous  acid  (P.B.  solution)  as  gives  a  green  colour.  If  more 
is  added,  the  colour  becomes  blue,  which  shows  that  rather  too  much  sulphurous 
acid  has  been  used.  It  is  well  to  reserve  a  few  drops  of  the  chromic  acid  solution 
to  be  added  after  the  blue  colour  has  just  appeared  and  restore  it  to  green. 
Then  enough  distilled  water  is  added  to  bring  the  green  liquid  up  to  480  gr.  Then 
add  the  sublimate  liquid. 

The  catgut  is  kept  twenty-four  hours  in  the  preparing  liquid  and  is  then  dried 
on  the  stretch. 

N.B.  It  is  essential  that  the  chromic  acid  and  the  sulphurous  acid  solutions  be 
mixed  before  the  corrosive  sublimate  solution  is  added. 


94  WOUNDS 

solution  for  a  long  time.  It  has  advantages  over  all  other  ligatures 
in  that  it  is  more  easily  absorbed  and  therefore  can  be  used  in  septic 
wounds.  It  is  absorbable  like  other  substances  only  when  actually  in 
contact  with  the  tissues,  that  is  to  say,  when  such  a  ligature  is  actually 
cast  off  into  an  abscess  cavity  it  will  remain  there  almost  indefinitely 
and  will  be  discharged  with  the  pus ;  when,  however,  the  ligature  is  in 
actual  contact  with  the  tissues  it  is  readily  absorbed.  Nevertheless,  it 
presents  sufficient  resisting  power  to  enable  it  safely  to  occlude  vessels 
and  to  close  wounds  in  internal  organs.  It  is  easily  tied,  the  knot  holds 
well,  and  it  is  not  in  any  way  irritating  to  the  tissues.  Although  much 
has  been  written  of  the  various  difficulties  of  sterilising  catgut,  we 
personally  have  experienced  none  of  them. 

Silk. — This  is  also  much  employed  for  sutures  and  ligatures.  We 
use  it  mainly  for  sutures.  It  is  very  slowly  absorbed,  and  as  a  ligature 
material  does  not  possess  any  advantages  over  catgut,  while  it  must  be 
afterwards  discharged  from  septic  wounds.  It  seems  to  us  a  disadvantage 
to  fill  a  wound  with  a  large  number  of  ligatures  of  a  material  which 
is  not  readily  absorbed.  Chinese  or  Japanese  twist  are  the  commonest 
varieties  of  silk  used,  the  latter  having  a  slight  advantage  from  the  point 
of  view  of  strength.  It  should  be  as  fine  as  possible,  usually  No.  3. 
Silk  can  be  readily  sterilised  by  boiling.  The  hanks  supplied  by  the 
instrument  makers  should  be  loosely  rewound  upon  glass  reels  or  small 
rolls  of  lint ;  if  the  latter  be  used,  the  end  of  the  thread  can  be  secured 
by  threading  it  upon  a  needle  which  is  then  thrust  through  one  end  of 
the  roll,  carrying  the  silk  with  it ;  the  needle  is  then  unthreaded  and  the 
silk  cut  off  so  as  to  leave  about  an  inch  of  it  hanging  loose.  About  two 
yards  of  the  silk,  sufficient  for  one  operation,  should  be  wound  upon 
each  roll  of  lint  and  the  pieces  thus  prepared  are  boiled  for  an  hour 
without  soda  and  are  then  transferred  to  a  closely  stoppered  vessel 
containing  a  I  in  20  carbolic  acid  solution  in  which  they  are  stored  until 
they  are  wanted  for  use.  Silk  prepared  in  this  manner  will  retain  its 
strength  for  many  months  ;  before  being  used  it  should  be  rinsed  in  a 
solution  of  i  in  2000  perchloride  of  mercury. 

When  an  aseptic  ligature  has  been  tied  round  a  vessel,  it  becomes 
buried  in  lymph  in  the  course  of  a  few  hours,  and  this  lymph  subsequently 
becomes  penetrated  with  cells  which  organise  into  fibrous  tissue,  and 
which  at  the  same  time  eat  away  the  outer  surface  of  the  ligature,  and 
penetrate  between  its  strands,  so  that  the  ligature  is  ultimately  replaced 
by  young  fibrous  tissue.  A  very  much  longer  time  is  occupied  by  this 
process  in  the  case  of  silk  than  in  the  case  of  catgut,  and  it  may  be  years 
before  the  silk  finally  disappears ;  sometimes  small  abscesses  form  and 
the  silk  is  discharged. 

Silkworm -gut. — This  is  a  useful  suture  material  prepared  from 
the  spinning  organs  of  the  silkworm  and  is  supplied  in  pieces  of  varying 
thicknesses  about  a  foot  long.  It  can  be  boiled  without  impairing  its 


OPERATIONS  AND  THEIR  MANAGEMENT  95 

strength.  Perhaps  the  most  convenient  method  of  storing  this  suture 
material  is  to  tie  a  thread  around  one  end  of  a  bundle  of  silkworm  gut 
and  to  pass  this  through  a  piece  of  drainage  tube  into  which  the  bundle  of 
silkworm  gut  can  be  drawn  by  traction  upon  the  thread.  The  thread 
is  then  unfastened,  leaving  the  silkworm  gut  inside  the  drainage  tube,  so 
that  one  or  more  threads  can  be  withdrawn  as  required. 

Horsehair. — This  is  prepared  by  soaking  it  in  a  I  in  20  carbolic 
acid  solution  for  a  week,  the  threads  being  stored  for  use  in  the  same 
solution.  If  preferred,  the  horsehair  may  be  sterilised  by  boiling.  A 
convenient  method  of  keeping  it  is  to  take  the  whole  wisp  of  horsehair 
and  double  it  in  half ;  the  loop  thus  formed  is  held  firmly  and  its  loose 
ends  divided  into  three  portions  which  are  plaited  together.  A  thread 
seized  in  the  middle  of  the  wisp  can  be  withdrawn  without  disturbing 
the  remainder. 

Silver  wire  is  readily  sterilised  by  boiling  or  by  passing  it 
through  the  flame  of  a  spirit  lamp.  In  straightening  a  silver  wire  each 
end  should  be  grasped  firmly  with  a  pair  of  forceps  and  twists  and  kinks 
undone  by  traction ;  friction  injures  its  ductility  so  that  it  cannot  be  tied 
into  a  knot.  Wire  that  is  too  brittle  can  have  its  ductility  restored  by 
heating  it  to  redness  in  a  spirit  lamp.  Fine  copper  or  aluminium  bronze 
wire  is  used  by  some  surgeons,  especially  in  America.  It  possesses  con- 
siderable pliability,  but  we  have  not  seen  any  special  advantage  in  it 
over  silver  wire. 

Kangaroo  Tendon. — This  material  is  mainly  employed  for  liga- 
ture in  continuity  of  large  vessels  such  as  the  innominate  artery.  It  is 
prepared  in  the  same  way  as  catgut,  but  it  has  several  disadvantages — it 
does  not  tie  well  and,  as  it  is  of  considerable  thickness,  the  sterilising 
process  must  be  very  prolonged  in  order  to  be  thorough,  otherwise  it 
is  liable  to  infect  the  wound. 

PREPARATION  OF  SPONGES,  SWABS  AND   DRESSINGS. 

Sponges. — The  proper  preparation  of  sponges  is  of  great  importance. 
In  our  opinion,  the  most  satisfactory  method  of  removing  blood  from  a 
wound  is  by  the  ordinary  marine  sponge.  In  the  first  place,  sponges  absorb 
blood  better  than  do  the  swabs  that  have  come  into  fashion  of  late 
years ;  and  in  the  second  place,  shreds  of  cotton  are  apt  to  be  left  behind 
in  the  wound  when  using  swabs.  When  properly  prepared,  both 
marine  sponges  and  absorbent  swabs  can  be  efficiently  sterilised,  but, 
as  they  are  often  prepared,  swabs  are  quite  unreliable.  We  have  never 
had  cause  to  complain  of  any  failure  of  the  sterility  of  marine  sponges. 
Sponges  should  be  close  in  texture  and  soft  yet  springy  when  wet ; 
Turkey  sponges  are  perhaps  the  best,  but  a  good  honeycomb  sponge  is 
almost  as  good.  The  meshes  of  the  sponge  frequently  contain  calcareous 
particles,  the  remains  of  the  skeleta  of  numerous  marine  animals,  and 
these  must  be  removed  by  cutting  out  the  larger  fragments  and  by 


96 


WOUNDS 


beating  and  shaking  ;  if  many  of  these  foreign  bodies  be  present  the 
sponge  should  be  rejected.  The  sponges  are  next  washed  in  plain  water 
containing  a  little  soda  or  soap  powder,  to  remove  dirt,  and  are  then 
rinsed  in  running  water  until  the  water  squeezed  out  of  them  is  perfectly 
clear  ;  they  are  then  soaked  for  twelve  hours  in  a  ten-per-cent.  solution 
of  hydrochloric  acid  to  remove  any  remaining  particles  of  calcareous 
matter,  after  which  they  are  again  rinsed  and  placed  in  a  strong  solution 
of  washing  soda  overnight ;  after  being  again  rinsed  in  clean  cold  water 
they  are  stored  for  use  in  a  covered  jar  containing  a  I  in  20  carbolic 
solution  which  should  be  changed  occasionally.  The  sponges  should 
not  be  used  for  at  least  forty-eight  hours  after  they  have  been  put  in  the 
carbolic.  This  method,  although  apparently  rather  complex,  is  really 
quite  simple  in  practice.  After  an  operation,  the  sponges  are  rinsed 
and  picked  clean  of  fibrin  and  other  solid  matter  ;  they  are  then  soaked 
for  twenty-four  hours  in  a  strong  solution  of  washing  soda,  rinsed 
thoroughly  in  running  water  and  returned  to  the  carbolic  solution,  where 
they  are  treated  as  before.  A  good  sponge  can  be  used  many  times, 
although  ultimately  it  becomes  hard  and  friable  and  must  be  discarded. 
Sponges  saturated  with  pus  or  tuberculous  material  should  not  be  used 
again. 

Swabs. — For  septic  cases  these  have  advantages  over  sponges  in  that 
large  numbers  can  be  prepared  and  thrown  away  when  they  have  been 
used.  They  may  be  prepared  either  by  cutting  a  roll  of  plain  gauze 
into  short  lengths  or  from  absorbent  wool.  A  single  layer  of  gauze  about 
nine  inches  square  is  taken  and  upon  the  centre  of  it  is  placed  a  mass  of 
wool,  about  the  size  of  a  small  orange  ;  the  opposite  corners  of  the  gauze 
square  are  then  tied  together  over  the  wool  so  as  to  enclose  it  completely 
and  to  diminish  the  risk  of  leaving  fragments  of  wool  behind  in  the 
wound.  The  swab  should  be  quite  soft  and  not  tightly  tied  up.  They 
may  be  sterilised  either  by  boiling,  by  means  of  a  high  pressure  autoclave, 
or  by  immersion  in  a  I  in  20  solution  of  carbolic  acid  for  twenty-four 
hours.  The  ordinary  steamer  in  which  sterilisation  is  attempted  at 
atmospheric  pressure  is  not  entirely  satisfactory  (vide  infra).  In  most 
cases  flat  swabs  are  more  useful  than  the  round  ones,  especially  if  the 
latter  be  made  firm  and  hard. 

Dressings. — Although  a  large  number  of  materials  for  dressings 
have  been  introduced,  we  are  in  the  habit  of  using  Lister's  double  cyanide 
gauze  and  salicylic  or  double  cyanide  wool  almost  exclusively.  This 
gauze  is  impregnated  with  the  double  cyanide  of  mercury  and  zinc,  a 
substance  which,  while  it  is  almost  insoluble  in  water,  does  dissolve 
slowly  in  albuminous  fluids  such  as  blood.  As  prepared  commercially 
it  is  liable  to  contain  a  small  quantity  of  free  perchloride  of  mercury. 
Although  the  antiseptic  contained  within  it  is  sufficient  to  inhibit  the 
growth  of  organisms  in  fluids  which  it  has  absorbed,  it  is  better  not  to 
trust  to  the  sterility  of  this  dressing  as  it  is  obtained  from  the  manu- 


OPERATIONS  AND  THEIR  MANAGEMENT 


97 


facturers.  An  autoclave  may  be  employed  for  sterilising  this  dressing, 
but  as  regards  aseptic  results  we  have  found  it  no  better  than  the  method 
of  sterilising  the  gauze  by  soaking  it  in  an  antiseptic  solution.  The  dry 
dressing  has  advantages,  however,  from  the  point  of  view  of  the  patient's 
comfort.  External  to  the  gauze  we  apply  a  mass  of  salicylic  or  double 
cyanide  wool  that  has  been  sterilised  in  an  autoclave. 

The  apparatus  for  sterilising  dressings  must  be  of  necessity  somewhat 


FIG.  24. — HIGH  PRESSURE  STEAM  STERILISER. — This 
form  of  instrument  is  suitable  for  private  work  or  a  small 
hospital.  The  dressings,  packed  in  suitable  drums  or 
boxes,  are  placed  in  the  inner  chamber.  The  water  jacket 
is  filled  about  three  parts  full,  the  level  of  the  water 
being  indicated  by  the  gauge  at  the  left-hand  side  of  the 
instrument.  A  large  gas  burner  is  then  lighted  beneath  the 
instrument,  and  when  steam  is  escaping  briskly  the 
cock  (2)  is  closed,  the  door  of  the  inner  chamber  is  tightly 
screwed  up  and  the  pressure  in  the  outer  chamber 
allowed  to  rise  until  the  pressure  gauge  indicates  15  Ib. 
to  the  sq.  in.  Cock  (5)  is  then  opened  and  steam 
allowed  to  pass  into  the  inner  chamber  and  expel  the  air, 
which  is  allowed  to  escape  through  cocks  (i)  and  (6). 
When  pure  steam  is  issuing  from  these  they  are  closed, 
and  the  communication  between  the  inner  and  outer 
chambers  cut  off  by  closing  cock  (5).  Cocks  (3)  and  (4) 
are  now  opened  so  as  to  produce  a  partial  vacuum  in  the 
inner  chamber,  the  gauge  for  which  is  shown  on  the  right- 
hand  side  of  the  instrument.  Cocks  (3)  and  (4)  are  now 
closed  and  steam  is  once  more  admitted  to  the  inner 
chamber  by  opening  cock  (5).  When  sterilisation  is  com- 
plete, the  vacuum  appliance  Is  once  more  brought  into 
play,  after  communication  between  the  two  chambers  has 
been  shut  off.  Air  is  then  admitted  by  opening  a  tap  (6) 
which  is  in  connection  with  a  small  metal  cup  containing 
sterilised  wool  to  filter  the  air  entering  the  sterilised 
chamber.  The  apparatus  can  be  emptied  by  opening 
cock  (7). 


costly,  and  in  consequence  many  so-called  sterilisers  have  been  intro- 
duced at  a  moderate  price ;  but  the  efficiency  of  these  is  very  doubtful. 
Inasmuch  as  the  antiseptic  requirements  can  be  met  amply  by  the  em- 
ployment of  chemical  antiseptics,  which  form  a  cheap  and  simple  method 
of  sterilisation,  the  use  of  dry  sterilised  dressings  is  not  to  be  recommended 
unless  a  thoroughly  efficient  apparatus  can  be  obtained.  The  apparatus 
which  we  use  is  shown  in  Fig.  24.  It  consists  of  an  inner  chamber,  in 
which  the  dressings  are  placed,  closed  by  a  steel  steam-proof  door.  This 
chamber  is  surrounded  by  a  water  jacket  which  can  be  heated  by  a 
powerful  gas  flame  placed  underneath.  The  flame  of  the  gas  burner  is 
directed  around  the  water  jacket  by  an  external  casing  lined  with 


gS  WOUNDS 

asbestos.  The  apparatus  is  fitted  with  appropriate  pressure  gauges, 
water  gauge,  and  safety  valve,  and  in  addition  there  is  a  steam  exhaust, 
by  means  of  which  a  partial  vacuum  can  be  produced  in  the  inner  chamber. 

The  dressings  or  other  articles  to  be  sterilised  are  placed  in  the  ordinary 
drums,  which  should  be  lined  with  lint  or  Gamgee  tissue  so  as  to  prevent 
any  dust  rinding  its  way  into  them  between  the  time  of  sterilising  and 
the  application  of  the  dressing.  It  is  important  to  pack  the  dressings 
loosely  so  as  to  allow  free  permeation  by  the  steam.  After  the  drums  have 
been  placed  within  the  steriliser,  the  perforations  in  their  side  being 
widely  open,  the  steam  door  is  closed  and  the  gas  burner  lighted  ;  when 
a  sufficient  head  of  steam  has  been  raised,  the  air  in  the  sterilising 
chamber  is  displaced  by  letting  in  the  steam  after  opening  one  of  the  stop- 
cocks leading  from  this  chamber.  When  pure  steam  is  issuing,  that  is 
to  say,  when  the  lower  portion  of  the  jet  in  contact  with  the  tap  is 
invisible,  the  steam  is  shut  off  from  the  inner  chamber  and  the  exhaust 
connected.  By  this  means  a  vacuum  of  eight  to  ten  inches  of  mercury 
can  be  produced.  This  means  that  if  steam  were  now  admitted  at  atmo- 
spheric pressure  to  the  dressing  chamber  it  would  permeate  one-fourth 
to  one-third  of  the  bulk  of  the  dressings.  The  sterilising  chamber  is 
now  connected  with  the  boiler,  and  steam  is  let  in  at  a  pressure  of  about 
twenty  pounds  to  the  square  inch.  The  object  of  using  steam  at  this 
pressure  is  twofold.  In  the  first  place,  the  pressure  causes  a  thorough 
permeation  of  the  dressings  by  the  steam,  leaving  but  little  to  the  process 
of  diffusion  ;  the  steam  is  forced  two-thirds  of  the  way  into  the  dressings 
immediately,  diffusion  sufficing  for  the  remaining  third.  In  the  second 
place,  the  temperature  of  steam  at  this  pressure  (260°  F.)  provides  for 
the  rapid  destruction  of  all  organisms  and  their  spores.  The  dressings 
are  left  in  the  sterilising  chamber  for  forty  minutes  ;  this  is  regarded  by 
many  as  an  excessive  time,  but  it  must  be  remembered  that  the  actual 
time  of  sterilisation  must  be  reckoned  from  the  moment  when  the  steam 
has  penetrated  the  innermost  recesses  of  the  dressings,  and  therefore 
to  ensure  thorough  sterility  it  is  as  well  to  allow  a  prolonged  exposure  to 
the  steam.  At  the  expiration  of  this  time  the  cock  connecting  the  boiler 
and  the  sterilising  chamber  is  closed  and  the  steam  exhaust  is  brought 
into  action  for  twenty  minutes  and  by  means  of  it  the  dressings 
are  thoroughly  dried.  Towards  the  conclusion  of  this  time  the  tap 
leading  from  the  sterilising  chamber  to  the  outer  air  is  open  and  air  is 
sucked  in  through  a  mass  of  sterilised  wool  which  effectually  niters  it. 
The  dressings  are  now  ready  to  be  removed  from  the  steriliser  and  may 
be  used  immediately  or,  if  the  tins  have  been  carefully  lined  and  the 
perforations  in  their  side  closed,  can  be  stored  until  they  are  required. 
The  salicylic  wool  loses  a  small  amount  of  salicylic  acid  in  this  process  but 
the  amount  is  negligible ;  the  double  cyanide  wool  is  unaltered. 

If  such  an  apparatus  be  not  obtainable,  all  that  is  necessary  is  to  place 
the  gauze  in  a  solution  of  perchloride  of  mercury,  I  in  2000,  which  is 


OPERATIONS  AND  THEIR  MANAGEMENT  99 

wrung  out  immediately  before  applying  the  dressing.  We  may  here  insist 
again  that  this  method  is  in  no  way  inferior  to  the  more  elaborate 
dry  sterilisation  except  from  the  point  of  view  of  the  patient's  comfort, 
and  is  immeasurably  superior  to  sterilisation  conducted  in  inefficient 
apparatus. 

THE  DANGERS  OF  OPERATIONS  AND  THEIR  PREVENTION. 

The  chief  immediate  risks  of  an  operation  are  the  dangers  of  the  anae- 
sthetic, the  introduction  of  sepsis,  loss  of  blood  and  shock  ;  of  somewhat 
less  importance  is  the  occurrence  of  syncope.  The  danger  of  anaesthetics 
is  dealt  with  separately  by  Dr.  Silk  (see  pp.  471  et  seq.). 

EXCLUSION    OF    MICRO-ORGANISMS. 

Exclusion  of  micro-organisms  is  the  really  essential  point  in  the  treat- 
ment of  wounds.  Even  if  the  steps  necessary  for  the  attainment  of  this 
object  were  to  interfere  with  healing  by  first  intention,  it  would  still  be 
incumbent  on  the  surgeon  to  see  that  they  were  carried  out,  on  account 
of  the  disastrous  results  that  follow  the  entrance  of  micro-organisms  into  a 
wound.  As  a  matter  of  fact,  however,  bacteria  can  be  excluded  without 
interfering  with  healing  by  first  intention  in  any  way.  The  exclusion  of 
organisms  during  and  after  the  performance  of  an  operation  is  the  essential 
Listerian  principle,  and  this  may  be  carried  out  in  two  ways.  The  one 
originally  introduced  by  Lister,  which  has  since  undergone  many  modifi- 
cations in  details,  consists  in  the  preliminary  disinfection  of  skin,  hands, 
instruments,  etc.,  in  the  use  of  antiseptic  substances  during  the  course 
of  the  operation,  and  in  the  subsequent  application  to  the  wound  of 
dressings  containing  antiseptics.  In  the  other  method  (sometimes  termed 
the  '  aseptic '  method),  the  procedures  are  essentially  the  same  in  the 
preliminary  stages,  but  the  use  of  antiseptic  substances  during  the  course 
of  the  operation  and  afterwards  in  the  dressings  is  avoided  (see  p.  153). 
There  is  no  real  antagonism  between  the  two  plans  ;  it  is  merely  a  difference 
in  the  mode  by  which  the  same  end  is  attained.  In  our  opinion,  the 
exclusion  of  micro-organisms  is  attained  in  practice  much  more  certainly 
by  the  intelligent  use  of  antiseptics  than  by  the  other  plan. 

Sources  of  Infection  by  Micro-Organisms. — Micro-organisms  may 
enter  a  wound  during  an  operation  firstly  from  the  skin  in  the  neighbour- 
hood of  the  wound  itself ;  secondly,  from  the  hands  of  the  operator  or  his 
assistants;  thirdly,  from  the  instruments,  ligatures,  etc.,  that  are  used 
during  the  course  of  the  operation ;  and  fourthly,  from  the  air.  If  the 
first  three  of  these  sources  be  properly  guarded  against,  it  will  practically 
always  be  possible  to  obtain  an  aseptic  wound.  The  organisms  which  fall 
in  from  the  air  are  usually  non-pathogenic,  and  will  not  grow  in  a  wound 
the  walls  of  which  are  brought  properly  into  contact. 

Disinfection  of  the  Skin. — Micro-organisms  are  always  present  on 

H  2 


ioo  WOUNDS 

the  skin  and  are  most  numerous  where  it  is  moist,  as,  for  example,  in  the 
axillae,  in  the  perineum,  between  the  toes,  and  in  the  various  folds  of  the 
skin.  They  are  found  not  only  in  the  old  epithelium  upon  the  surface, 
but  also  about  the  hairs,  and  they  seem  to  penetrate  to  a  certain  dis- 
tance into  the  hair  follicles  and  sebaceous  glands  ;  hence  their  complete 
eradication  is  a  matter  of  some  difficulty.  In  order  to  get  rid  of  them, 
antiseptic  substances  must  be  used,  whichever  of  the  two  methods 
referred  to  above  is  to  be  employed. 

We  practise  and  strongly  recommend  the  following  method  of  disin- 
fecting the  skin :  The  skin  should  be  shaved  for  a  considerable  distance 
round  the  area  of  the  proposed  operation.  A  lather  of  ether  soap  and  i  in 
20  carbolic  acid  solution  should  be  used.  After  shaving,  the  part  is 
thoroughly  washed  with  soap  and  i  in  20  carbolic  solution,  or  still  better, 
a  i  in  20  watery  solution  of  carbolic  acid  containing  -g^th  part  of  corro- 
sive sublimate  (this  we  have  already  referred  to  as  the  '  strong  mixture '). 
This  cleansing  should  be  prolonged  and  thorough ;  the  first  washing  should 
be  done  with  the  hands,  and  afterwards  the  skin  should  be  scrubbed  with 
a  sterilised  nail-brush  and  strong  mixture.  If  possible,  this  purification 
should  take  place  some  hours  before  the  operation,  and  a  piece  of  gauze 
soaked  in  a  i  in  40  carbolic  solution,  but  without  any  mackintosh  outside 
it,  should  be  fixed  over  the  part  so  as  to  prolong  the  disinfection  ;  in  any 
case,  the  process  should  be  repeated  immediately  before  the  operation. 
Before  the  incision  is  made,  the  strong  mixture  remaining  on  the  surface 
of  the  skin  should  be  washed  away  with  a  i  in  2000  sublimate  solution. 
It  is  always  necessary  to  purify  a  wide  area  of  the  skin  around  the 
neighbourhood  of  the  operation  wound. 

Precautions. — In  children  or  those  suffering  from  pyrexia  (for  example, 
hectic  fever),  it  is  advisable  not  to  wrap  the  part  up  in  a  carbolic  dressing 
after  disinfection,  as  the  drug  is  apt  to  be  absorbed  and  may  lead  to 
dangerous  symptoms  of  poisoning  ;  in  these  cases  the  wet  gauze  or  cloth 
which  is  afterwards  put  on  to  continue  the  disinfection  should  be  soaked 
in  a  I  in  2000  sublimate  solution.  The  carbolic  acid  may  be  used  for 
the  disinfection  of  the  skin  immediately  before  the  operation,  but  then 
little  if  any  absorption  will  occur. 

Various  other  methods  of  disinfecting  the  skin  are  employed,  but 
none  of  them  are  as  certain  as  the  above.  Mechanical  cleansing  of  the 
skin  with  sterile  water  is  quite  inefficient.  Alcohol  is  neither  strong 
enough  nor  rapid  enough  in  its  action,  and  penetrates  the  epidermis 
badly;  the  best  of  the  alcoholic  solutions  is  i  in  2000  biniodide  solu- 
tion in  70  per  cent,  methylated  spirit.  Painting  the  skin  over  with 
tincture  of  iodine  has  come  into  vogue  lately,  but  it  possesses  no 
advantages  over  carbolic  acid  and  is  apt  to  leave  the  skin  tender  and 
easily  irritated  by  the  dressings,  while  it  also  leaves  a  quantity  of  old 
epithelium  beneath  which  bacteria  may  spread  into  the  wound  after  the 
operation. 


OPERATIONS  AND  THEIR  MANAGEMENT  101 

Disinfection  of  the  Hands.— Before  using  any  disinfectant  solu- 
tion, the  hands  should  be  thoroughly  washed,  preferably  in  a  running 
stream  of  hot  water,  the  nails  should  be  trimmed  and  all*tags  or 
scales  of  epithelium  removed  with  scissors  or  pumice  stone.  A  large 
number  of  experiments  have  been  made  to  determine  how  far  the  hands 
can  be  disinfected  by  purely  mechanical  means,  and  the  success  which 
has  followed  some  of  these  experiments  has  led  to  an  exaggerated  idea 
as  to  the  efficacy  of  mechanical  disinfection.  It  is  no  doubt  possible 
to  diminish  very  largely  the  number  of  micro-organisms  by  prolonged 
scrubbing  with  a  sterile  brush  and  soap  under  a  running  stream  of  hot 
sterilised  water,  but  it  cannot  be  insisted  upon  too  strongly  that  the 
essential  point  in  disinfection  of  the  hands  is  the  application  of  a  chemical 
disinfectant,  the  '  scrubbing  up  '  merely  facilitating  the  action  of  the 
disinfectant  by  removing  gross  dirt.  The  skin  of  the  hands  of  the 
surgeon  and  his  assistants  must  therefore  be  disinfected  in  a  manner 
exactly  similar  to  that  employed  in  the  disinfection  of  the  patient's  skin 
(see  p.  100).  Although  the  use  of  india-rubber  gloves  has  solved  many 
difficulties  in  connection  with  disinfection  of  the  hands,  it  does  not  allow 
any  relaxation  to  be  made  in  the  stringency  of  the  methods  employed  for 
sterilising  the  hands  before  the  gloves  are  put  on. 

The  method  we  employ  is  as  follows:  The  patient  is  placed  in  the 
desired  position  on  the  operating  table,  the  preparatory  disinfection 
dressing  is  removed  and  mackintoshes  are  arranged  around  the  field  of 
operation.  During  these  manipulations  there  is  a  risk  of  depositing 
infective  material  upon  the  skin  of  the  patient  or  the  hands  of  the 
surgeon  and  we  therefore  disinfect  our  hands  and  the  patient's  skin 
(see  p.  100)  afresh  before  the  wet  towels  (see  p.  102)  are  arranged  around 
the  field  of  operation.  At  this  stage  it  is  common  to  see  the  operator 
and  his  assistants  wash  their  hands  with  ordinary  soap  and  water. 
Any  washing  after  the  final  disinfection  of  the  patient's  skin  should 
be  done  with  an  antiseptic  solution,  the  detergent  powers  of  which 
are  superior  to  that  of  water. 

Gloves. — If  gloves  are  to  be  worn,  they  should  be  put  on  at  this  stage. 
Gloves  are  best  sterilised  by  half-filling  them  with  hot  water  and  boiling 
for  half-an-hour.  Before  being  drawn  on  the  hands,  they  should  be 
filled  with  a  i  in  4000  solution  of  perchloride  of  mercury.  If  the  glove's 
be  filled  with  the  lotion,  there  should  be  no  difficulty  in  putting  them  on 
rapidly.  If  they  do  not  fit  at  the  ends  of  the  fingers  they  should  be  brushed 
upwards  from  the  finger-tips  towards  the  wrists  with  a  nail  brush  until 
they  are  quite  smooth.  The  surgeon  should  always  wear  gloves  that  fit 
perfectly  and  are  somewhat  on  the  stretch,  as  the  diminution  of  tactile 
sensation  is  thereby  reduced  to  a  minimum.  The  assistants'  gloves  need 
be  neither  so  thin  nor  so  accurately  fitting.  Gloves  with  slightly 
roughened  surfaces — the  so-called  '  never-slip  '  variety — are  superior  to 
smooth  ones. 


102  WOUNDS 

Precautions  during  the  Course  of  an  Operation.— Precautions 
must  be  taken  to  see  that  no  infection  of  the  instruments,  sponges,  etc., 
occurs  during  the  course  of  the  operation.  The  most  essential  of  these 
precautions  is  to  surround  the  area  of  the  operation  with  aseptic  towels 
wrung  out  of  a  hot  antiseptic  solution.  If  these  wet  aseptic  towels 
be  placed  all  around  the  area  of  operation,  instruments  laid  down  upon 
them  do  not  become  contaminated,  and  the  same  is  the  case  if  the  hands 
of  the  operator  or  his  assistants  rest  upon  them.  At  the  hospitals  with 
which  we  are  connected  the  towels  are  boiled  and  then  put  to  soak  for 
two  or  three  hours  before  the  time  fixed  for  the  operation  in  hot  I  in  2000 
sublimate  solution  in  a  vessel  with  a  tight-fitting  lid  or  a  hot-water  jacket ; 
they  are  then  lightly  wrung  out  and  arranged  around  the  field  of  operation. 
Towels  prepared  in  this  way  are  quite  aseptic,  and  in  private  practice 
it  is  easy  to  instruct  a  nurse  to  do  this.  For  operations  of  emergency, 
it  will  suffice  to  boil  the  towels  and  then  wring  them  out  of  hot  I  in  2000 
sublimate . 

The  clothes  and  blankets  in  contact  with  the  patient  must  be  covered 
with  mackintoshes  (the  most  convenient  are  those  made  of  thin  jaconet), 
and  outside  these,  towels,  prepared  as  just  described,  should  be  spread 
in  all  directions,  so  that  nothing  can  by  any  chance  be  laid  on  septic 
objects,  such  as  blankets,  sheets,  etc.  During  the  operation  also,  the 
instruments  should  be  handed  to  the  surgeon  direct  from  an  antiseptic 
solution  ;  although  the  small  amount  of  carbolic  acid  which  might  enter 
the  wound  from  the  forceps,  knives,  etc.,  is  not  really  injurious,  it  is  well, 
in  order  to  avoid  unnecessary  irritation,  to  rinse  the  instruments  in  a 
i  in  2000  sublimate  solution  before  using  them ;  basins  of  this  lotion 
should  be  beside  the  operator  and  his  assistants  during  the  operation, 
and  after  an  instrument  has  been  used,  it  shouid  be  rinsed  in  the  sub- 
limate solution  before  being  used  again. 

A  word  of  caution  may  be  given  concerning  the  manner  of  handing 
ligatures  and  sutures  to  the  surgeon.  It  is  too  frequently  the  custom  to 
seize  the  ligature  by  one  end  and  hand  it  with  the  other  hanging  free. 
The  consequence  is  that  its  free  end  is  very  likely  to  come  into  contact 
with  some  unpurified  object,  such  as  a  blanket  or  an  article  of  clothing, 
in  transit,  and  sepsis  may  thus  be  introduced  into  the  wound.  All  ligatures 
and  sutures  should  either  be  given  to  the  surgeon  with  the  free  end  coiled 
up  in  the  palm  of  the  hand,  or  one  end  should  be  taken  in  each  hand,  and 
special  care  taken  to  see  that  the  intervening  portion  does  not  touch  any 
unpurified  object. 

Certain  precautions  as  to  dress  must  be  taken  by  the  surgeon  and  his 
assistants  in  order  to  avoid  accidental  contamination  of  the  wound  during 
the  course  of  an  operation.  The  sleeves  should  be  rolled  up  well  above  the 
elbow,  and  a  mackintosh  apron  reaching  from  the  collar  to  the  ground  and 
furnished  with  sleeves  reaching  to  the  elbow  should  be  worn.  The  outer 
surface  of  this  apron  is  well  sponged  over  with  i  in  20  carbolic  lotion,  and 

~,Cj    HrjHJ. 


OPERATIONS  AND  THEIR  MANAGEMENT 


103 


over  it  is  fastened  a  bib  sterilised  by  boiling  and  wrung  out  of  i  in  2000 
sublimate  solution.  This  is  donned  immediately  before  the  operation  is 
begun  (see  Fig.  25).  This  is  better  than  the  sterilised  linen  gown  which  is 


FIG.  25. — OPERATING  DRESS. — This  consists  of  a 
mackintosh  overall,  to  the  front  of  which  a  boiled 
bib  is  buttoned.  Rubber  gloves  are  also  shown. 
This  apparatus  can  be  prepared  without  a  high- 
pressure  steriliser,  and  is  therefore  suitable  for 
operations  in  private  houses  where  such  an 
appliance  is  not  available. 


FIG.  26. — SURGEON  WEARING  OVERALL  AND 
COMBINED  CAP  AND  MASK. — This  apparatus  must 
be  sterilised  in  a  high  pressure  steriliser  of  the 
type  shown  in  Fig.  24. 


usually  employed  (see  Fig.  26),  because  it  keeps  the  surgeon's  clothes 
from  getting  soiled,  and  because  the  antiseptic  bib  remains  aseptic 
during  the  operation.  Each  assistant  should  take  precautions  similar 
to  those  employed  by  the  surgeon,  and  should  always  wear  sterilised 
rubber  gloves  whether  the  surgeon  uses  them  or  not.  Caps  and  masks  or 


104 


WOUNDS 


veils  are  used  by  many  surgeons  as  a  matter  of  routine,  but  though 
advisable  they  are  not  absolutely  necessary,  unless  the  surgeon  suffers 
from  dandruff  or  sweats  profusely,  when  he  should  wear  a  cap ;  or  has 
a  bad  cough  or  cold,  when  he  should  wear  a  veil.  It  is  well  to  remem- 
ber that  organisms  may  be  projected  from  the  operator's  mouth  into  the 
wound  during  loud  talking,  and  therefore  all  unnecessary  conversation 
should  be  avoided  during  an  operation  and  the  voice  tones  kept  at  a 
low  level.  No  surgeon  who  has  any  serious  septic  condition  of  the  nose 
or  throat  should  do  an  operation  until  he  has  recovered  from  it. 

Management  of  Sponges. — The  sponges,  when  removed  from  the  jar 
in  which  they  are  kept,  should  be  rinsed  in  a  i  in  2000  sublimate  solution, 
and  should  never  be  washed  in  ordinary  water  during  the  course  of  the 
operation.  When  they  have  become  soaked  with  blood,  they  should  first 
be  squeezed  as  dry  as  possible,  then  rinsed  thoroughly  in  a  cold  i  in  2000 
sublimate,  and  placed  in  a  basin  containing  a  similar  warm  solution,  out 
of  which  the  surgeon  wrings  them  before  use.  Every  bowl,  dish,  or  tray 
used  during  the  operation  should  be  sterilised  outside  and  in,  as  there  is 
always  a  chance  of  some  part  of  it  coming  into  contact  with  the  hands, 
the  instruments,  the  wound,  or  the  field  of  operation.  This  may  be  done 
in  an  autoclave  or  by  boiling.  Failing  either  of  these  methods,  they 
should  be  immersed  for  an  hour  or  more  in  a  i  in  20  carbolic  solution,  or, 
failing  that,  scrubbed  thoroughly  with  it.  The  nurse  should  of  course 
disinfect  her  hands ;  but,  as  she  is  constantly  soiling  them,  she  should 
not  be  allowed  to  wring  out  and  hand  the  sponges  ;  if  she  does,  she  must 
disinfect  her  hands  scrupulously  and  must  be  told  off  exclusively  to  hand 
sponges.  This  is  an  important  point  which  is  constantly  neglected. 

Avoidance  of  Aerial  Infection. — At  one  time  considerable  stress 
was  laid  upon  the  chance  of  wound  infection  by  the  air,  but  we  now  know 
that  the  organisms  generally  met  with  in  the  air  are  saprophytes,  which 
do  not  grow  in  the  tissues ;  in  fact,  they  are  non-parasitic  organisms. 
Hence  the  risk  from  organisms  falling  into  the  wound  from  the  air,  and 
giving  rise  to  trouble,  is  comparatively  slight.  At  the  same  time  it  must 
be  admitted  that,  in  a  hospital  ward  where  a  case  of  erysipelas  may  be 
present,  there  would  be  such  a  risk,  and  in  hospital  practice  there  must 
always  be  a  certain  degree  of  danger  from  this  source. 

When  instruments,  sponges,  etc.,  are  always  immersed  in  antiseptic 
solutions  any  aerial  organisms  which  come  into  contact  with  them  are 
rendered  inert,  for  though  spore-bearing  organisms  may  not  be  destroyed, 
the  non-spore-bearing  forms  such  as  those  of  erysipelas  are  killed  at 
once. 

HEMORRHAGE  AND  THE    MEANS  OF   ARRESTING  IT. 

Bleeding  may  be  arterial,  venous,  or  capillary  in  nature.  In  arterial 
bleeding,  blood  of  a  bright  red  colour  spurts  from  the  cut  vessel  synchron- 
ously with'the  systole  of  the  heart,  and  flows  continuously  during  the 


OPERATIONS  AND  THEIR  MANAGEMENT  105 

diastole.  In  venous  bleeding  there  is  a  steady  flow  of  dark  blood,  except 
in  the  case  of  the  veins  of  the  neck,  where  it  escapes  in  jets  at  each 
expiration,  with  a  steady  flow  between.  Capillary  bleeding  is  an  oozing 
from  the  surface  of  the  wound. 

Spontaneous  Arrest  of  Bleeding. — Bleeding  from  any  of  these 
sources  may  cease  spontaneously,  failing  which,  special  means  will  be 
necessary  to  arrest  it.  The  mode  in  which  haemorrhage  ceases  spon- 
taneously differs  according  to  the  blood-vessels  concerned  in  the  bleeding. 
In  the  case  of  arteries  divided  transversely,  the  circular  fibres  of  the 
muscular  coat  contract  so  that  the  orifice  of  the  vessel  is  narrowed ;  at 
the  same  time  the  internal  and  middle  coats  curl  up  in  the  interior  of 
the  vessel,  and  the  longitudinal  fibres  contract  and  shorten  it,  so  that  it 
retracts  within  its  sheath.  These  changes  are  followed  by  clotting  of  the 
blood ;  as  soon  as  the  blood  comes  in  contact  with  tissues  which  are  injured, 
or  which  are  not  similar  to  the  healthy  lining  membrane  of  the  vessels,  it 
undergoes  coagulation.  Consequently,  clotting  tends  to  take  place  as 
soon  as  the  blood  escapes  from  the  vessel,  unless  the  flow  of  blood  be  so 
free  that  the  clot  is  swept  away  by  it.  In  the  case  of  small  vessels,  clotting 
occurs  where  the  blood  comes  in  contact  with  the  divided  coats,  more 
especially  between  the  vessel  and  its  sheath,  and  the  clot  formed  there 
tends  to  occlude  the  ends  of  the  artery  still  further  by  its  pressure.  This 
clot  forms  a  mechanical  obstacle  to  the  escape  of  the  blood  (provided 
that  the  force  of  the  blood  stream  be  not  sufficient  to  expel  it),  and  it 
soon  extends  upwards  into  the  interior  of  the  vessel,  in  most  cases  as 
far  as  the  nearest  collateral  branch.  The  result  is  that  a  conical  wedge 
of  blood-clot  is  formed  inside  the  vessel,  which  is  very  effectual  in  bringing 
about  cessation  of  the  bleeding. 

The  endothelial  cells  then  begin  to  multiply  in  the  neighbourhood 
of  the  clot  which  they  rapidly  cover.  Losing  their  typical  flattened 
shape  they  grow  into  the  substance  of  the  clot,  and  from  them  is  formed 
a  large  amount  of  the  connective  tissue  which  replaces  the  thrombus. 
At  the  same  time  connective  tissue  grows  in  from  the  neighbouring  parts, 
so  that  the  divided  end  of  the  vessel  becomes  completely  occluded  by 
fibrous  tissue  and  shrinks  up.  Ultimately  a  small  fibrous  cord  is  all  that 
remains  to  represent  the  vessel  from  the  seat  of  division  to  the  nearest 
collateral  branch.  When  an  artery  is  only  partially  cut  across,  the  con- 
traction and  retraction  of  its  coats  tend  to  enlarge  the  orifice,  and  so  to 
increase  bleeding  rather  than  diminish  it,  and  in  these  cases  the  natural 
haemostatic  process  cannot  occur  until  the  vessel  has  been  completely 
divided. 

Capillary  bleeding  ceases  simply  as  the  result  of  coagulation  of  blood 
in  the  capillaries.  Venous  bleeding  ceases  as  the  result  of  the  formation 
of  a  small  clot  outside  the  vein  and  the  subsequent  sealing  of  the  part  with 
lymph  when  the  vein  is  only  partially  divided ;  when  the  division  is 
complete,  clotting  occurs  and  the  vein  becomes  closed  by  adhesion. 


I06  WOUNDS 

It  does  not  necessarily  follow  that  a  clot  will  form  in  the  interior  of  a  vein 
if  the  latter  be  only  partially  divided. 

Means  of  controlling  Haemorrhage.— When  a  large  artery  has 
been  divided  or  when  a  small  one  has  only  been  partially  cut  across, 
the  bleeding  will  not  stop  spontaneously,  and  some  artificial  means 
must  be  adopted  to  arrest  it.  Capillary  bleeding,  on  the  other  hand, 
is  only  troublesome  in  cases  of  haemophilia,  where  coagulation  of  the 
blood  does  not  take  place  properly,  and  very  persistent  oozing  may 
occur.  Bleeding  from  a  partially  divided  vein  usually  ceases  spon- 
taneously, except  when  severe  coughing  or  crying  gives  rise  to  an 
obstruction  to  the  flow  of  blood  through  the  veins,  and  leads  to  expulsion 
of  blood  through  the  divided  wall. 

Tourniquets. — It  is  necessary  to  consider  not  only  the  arrest,  but 
also  the  prevention  of  haemorrhage.  Under  certain  circumstances  it  is 
advisable  to  arrest  the  circulation  in  the  part  upon  which  an  operation 


FIG.  27. — ESMARCH'S  RUBBER  TOURNIQUET. — The  appliance  which  consists  of  a 
length  of  rubber  tubing  is  tightly  wound  two  or  three  times  round  the  limb  and 
secured  by  the  anchor  catch  in  the  method  shown. 

is  being  performed.  Formerly  this  was  done  by  means  of  a  tourniquet, 
a  band  tied  tightly  round  the  limb,  furnished  with  a  screw  and  a  pad 
which  was  placed  over  the  artery,  and  screwed  up  until  the  circulation 
through  the  vessel  was  arrested. 

Esmarch's  Bandage. — The  chief  disadvantage  of  the  old  tourniquet  is 
that,  while  it  arrests  the  flow  of  blood  through  the  main  vessel,  it  does 
not  control  the  collateral  circulation.  At  the  present  time  a  rubber 
band,  with  which  the  name  of  Esmarch  is  associated,  is  wound  firmly 
round  the  upper  part  of  the  limb  and  in  this  way  the  entire  circulation 
through  the  limb  is  effectually  controlled.  In  amputations  in  weakly 
patients  it  is  also  of  importance  to  preserve  the  blood  which  is  already 
present  in  the  limb.  Esmarch's  plan  is  to  bandage  the  limb  spirally  from 
the  extremity  upwards  with  a  broad  elastic  bandage  applied  very  firmly, 
so  as  to  expel  all  the  blood  from  the  vessels  ;  when  the  upper  part  of  the 
limb  is  reached,  a  rubber  tube  or  cord  is  applied  transversely  around  it, 
and,  when  this  has  been  fastened,  the  spiral  elastic  bandage  is  taken  off. 
This  method  is  both  unnecessary  and  frequently  undesirable.  It  is  very 


OPERATIONS  AND  THEIR  MANAGEMENT  107 

undesirable  in  cases  of  tumours  or  of  suppuration,  as  in  them  the 
elastic  bandage  is  apt  to  squeeze  pus  or  tumour  substance  into  the 
tissues  or  vessels  during  its  application,  and  thus  serious  results  may  be 
caused. 

Lister's  Method. — On  the  other  hand,  the  plan  introduced  by  Lord 
Lister,  of  elevating  the  limb  for  a  few  minutes  before  applying  the  elastic 
tourniquet,  suffices  to  empty  the  limb  of  blood.  If  the  limb  be  elevated,  the 
veins  collapse  immediately,  and  the  main  arteries  contract  reflexly,  so 
that  the  limb  becomes  practically  bloodless  if  the  elevated  position  be 
maintained  for  two  or  three  minutes.  When  this  has  been  done  and 
while  the  limb  is  still  raised,  india-rubber  tubing  is  wound  firmly  around 
its  upper  part.  In  this  way,  it  is  easy  to  obtain  a  field  of  operation 
as  free  from  blood  as  by  Esmarch's  method  without  any  risk  of  dis- 
seminating pus  or  tumour  substance. 

It  is  only  in  a  few  cases  that  this  bloodless  plan  is  of  real  advantage. 
It  is  of  great  value  in  operations  such  as  suture  of  nerves  or  tendons, 
where  delicate  dissection  would  be  marred  by  the  presence  of  blood  in  the 
wound.  In  amputations,  too,  it  is  valuable,  as  the  main  vessel  and  its 
larger  branches  can  be  tied  before  the  blood  is  allowed  to  flow  through  the 
vessels  again.  It  is  also  useful  in  operations  for  necrosis,  as  it  allows  the 
surgeon  to  distinguish  easily  between  the  living  and  the  dead  structures  ; 
but  it  is  not  so  good  in  cases  of  tuberculous  joints,  where  the  accurate 
recognition  cf  the  diseased  tissues  depends  to  a  considerable  extent  on 
the  vascularity  of  the  part. 

Objections  to  'Bloodless  Methods.' — There  is  one  great  general  objection 
to  the  use  of  Esmarch's  bandage  and  the  principle  of  bloodless  operations 
generally.  It  is  that,  if  the  operation  be  a  prolonged  one,  the  after-bleed- 
ing is  very  severe,  and  the  amount  of  blood  lost  by  the  patient  is  probably 
as  great  when  the  bandage  is  used  as  when  it  is  not.  Moreover,  a  longer 
time  is  spent  over  the  operation,  because  an  unduly  large  number  of  vessels 
must  be  tied,  and  it  is  not  wise  to  sew  up  the  wound  until  the  oozing  has 
stopped.  When  the  bandage  is  removed,  the  vessels  dilate,  the  limb 
flushes  and  becomes  redder  than  its  fellow,  and  there  is  a  certain  amount  of 
vaso-motor  paralysis,  in  consequence  of  which  many  vessels  go  on  bleeding, 
and  require  ligature  ;  had  the  bandage  not  been  used,  this  bleeding 
would  have  stopped  almost  immediately.  Blood  may  also  collect  in  the 
wound  after  it  has  been  sutured,  and  interfere  with  union. 

Ligature. — Temporary. — In  some  cases  haemorrhage  is  prevented  by 
occluding  the  main  vessels  supplying  the  part  either  by  means  of  a 
permanent  ligature  or  by  the  application  of  a  temporary  ligature,  digital 
compression,  or  Crile's  clamps.  In  applying  a  temporary  ligature  care 
must  be  taken  to  injure  the  vessel  as  little  as  possible  ;  the  ligature  should 
be  broad ;  a  piece  of  tape,  a  kangaroo  tendon  or  a  thin  rubber  band 
answer  very  well.  It  is  best  not  to  tie  these  temporary  ligatures  ;  it  is 
sufficient  to  make  gentle  traction  upon  the  ends  of  the  loop  around  the 


I08  WOUNDS 

vessel  and  thus  draw  it  up  to  the  surface.     This  produces  a  partial 
kink  which  is  sufficient  to  check  the  flow  of  blood. 

Permanent.—  When  bleeding  does  not  cease  spontaneously  soon  after 
division  of  an  artery,  it  is  well  to  apply  a  ligature  to  the  vessel.  The 
effect  of  this  is  to  divide  the  internal  and  middle  coats,  which  curl  up  in 
the  interior  of  the  vessel,  and  also  to  constrict  the  external  coat  firmly, 
so  as  to  prevent  the  escape  of  blood.  The  materials  used  for  ligatures 
may  be  absorbable  or  non-absorbable,  or  absorbable  only  with  great 
difficulty.  The  best  of  the  absorbable  materials  is  catgut,  which  has  been 
already  'dealt  with  fully  in  connection  with  suture  materials  ;  its  mode 
of  preparation  will  be  found  on  p.  93.  Catgut  prepared  according  to 
Lord  Lister's  recommendations  is  a  most  satisfactory  ligature  material. 


FIG.  28. — CHILE'S  CLAMPS  FOR  TEMPORARY   H^MOSTASIS. — The  blades  should 
be  sheathed  in  rubber  tubing. 

Cautery. — In  parts  where  ligatures  cannot  be  applied,  e.g.  the  bladder, 
the  bleeding  may  be  arrested  by  means  of  the  cautery,  the  most  convenient 
form  being  Paquelin's.  It  must  not  be  used  white-hot,  as  in  that  case  it 
will  cut  through  the  vessel,  and  bleeding  will  persist ;  it  should  be  allowed 
to  cool  until  it  is  hardly  red.  When  a  hot  point  like  this  is  held  in  contact 
with  a  vessel,  it  sears  the  tissues  so  that  they  stick  together,  and  clotting 
occurs  inside  the  artery. 

Torsion. — Another  way  in  which  arterial  bleeding  may  be  arrested  is 
by  torsion.  The  object  of  torsion  is  to  twist  the  end  of  the  artery  so  that 
the  middle  and  internal  coats  are  ruptured  and  curl  up,  while  the  twisted 
external  coat  forms  an  obstacle  to  the  escape  of  blood.  In  order  to  do 
this,  •  the  artery  must  be  fixed  above  the  point  at  which  the  coats  are 
to  be  ruptured,  as  otherwise,  in  a  large  artery  at  any  rate,  the  only 
effect  would  be  to  twist  the  artery  round  and  round  in  its  sheath  for  a 
great  distance  without  attaining  the  desired  result.  A  large  artery,  there- 
fore, should  be  pulled  out  of  its  sheath  and  grasped  with  a  pair  of  forceps 
transversely  to  its  long  axis  above  the  point  at  which  the  torsion  is 
to  be  employed ;  the  cut  end  of  the  artery  is  then  grasped  with 
another  pair  of  forceps,  and  twisted  until  the  coats  are  felt  to  give  way. 
Four  complete  revolutions  are  generally  enough.  It  suffices  to  get 
a  small  artery  as  free  from  the  surrounding  tissues  as  possible,  to  grasp 
the  tissues  above  it  firmly  with  the  fingers  of  one  hand,  and  then  twist  up 
the  part  seized  by  the  forceps  with  the  other  hand.  Although  torsion 
answers  very  well  in  many  cases,  we  cannot  recommend  it  as  a  satisfactory 
substitute  for  ligature.  It  was  introduced  before  the  aseptic  period, 


OPERATIONS  AND  THEIR  MANAGEMENT 


109 


when  ligatures  had  to  separate,  and  when,  therefore,  there  was  a  danger 
of  secondary  haemorrhage  ;  now  that  ligatures  are  cut  short  and  never 
separate  from  the  divided  ends  of  the  artery,  there  is  no  risk  of  secondary 
haemorrhage,  and  torsion  is  rarely  used  except  for  small  vessels.  It 
is,  however,  very  useful  for  them  in  certain  cases,  such  as  those  in  which 
there  is  a  certainty  or  a  probability  of  the  wound  becoming  septic.  Here 
the  absence  of  ligatures  from  the  wound  may  allow  much  earlier  healing 
than  would  otherwise  occur.  It  is  also  useful  for  superficial  vessels  such 
as  those  of  the  skin.  If  these  be  ligatured,  the  ends  of  the  ligatures  are 
apt  to  project  between  the  lips  of  the  wound. 


FIG.  29. — PRESSURE  FORCEPS  FOR  ARREST  OF  HEMORRHAGE. — The  above  are  the 
varieties  in  common  use.  A,  Lawson  Tail's,  very  similar  to  Spencer  Wells's,  but  tapered 
at  the  points  so  as  to  facilitate  the  application  of  a  ligature  ;  this  is  still  further  facilitated 
in  the  pattern  B,  which  is  useful  in  tying  vessels  at  the  bottom  of  a  deep  wound.  C, 
Greig  Smith's  ;  these  forceps  are  designed  to  crush  the  walls  of  a  vessel  firmly  together, 
and  at  the  same  time  to  cut  through  their  inner  and  middle  coats.  The  full-size  illus- 
tration of  the  blade  shows  how  this  is  done. 

Pressure.— Pressure  is  also  a  very  important  method  of  arresting 
haemorrhage,  especially  of  the  venous  or  capillary  variety  ;  venous  bleed- 
ing can  be  readily  arrested  by  it,  and  in  many  cases  in  which  it  is 
undesirable  to  have  ligatures  on  the  surface  of  the  wound,  as  for  instance, 
in  operations  about  the  lips,  the  surgeon  makes  use  of  pressure  to 
arrest  the  haemorrhage.  The  pressure  stops  the  flow  of  blood  through 
the  vessel  while  a  clot  is  being  formed.  A  method  of  employing  pressure 
that  has  enjoyed  a  considerable  vogue  is  by  means  of  the  'graduated 
compress.'  When  the  bleeding  point  is  deeply  seated,  and  it  is  not  desired 
to  open  up  the  wound,  pressure  may  be  employed  to  arrest  the  haemorrhage. 
If,  however,  the  pressure  be  applied  in  the  form  of  a  simple  pad  over  the 
surface  of  the  wound,  the  bleeding  may  go  on  in  the  interior ;  a  good 


no  WOUNDS 

example  is  bleeding  from  the  socket  of  a  tooth  after  the  latter  has  been 
extracted.  Cases  of  this  kind  require  the  application  of  a  graduated 
compress  ;  a  tiny  piece  of  gauze  or  lint  is  placed  on  the  bleeding  point, 
then  pieces  are  added,  gradually  increasing  in  size  until  a  conical  pad  is 
formed,  the  outer  part  of  which  projects  well  above  the  surface.  Then 
pressure  is  applied  through  the  cone  actually  on  to  the  bleeding  point 
by  means  of  a  bandage,  or,  in  the  case  of  a  tooth,  by  fixing  the  two  jaws 
together. 

Temporary  Pressure  by  Forceps. — The  haemorrhage  from  small  vessels 
can  often  be  arrested  by  pinching  them  tightly  in  strong  forceps,  such  as 
Spencer  Wells's,  or,  perhaps  even  better,  those  devised  by  Greig  Smith 
(see  Fig.  29).  If  the  various  bleeding  points  be  compressed  in  this  way 
as  the  operation  proceeds  and  the  forceps  be  left  on,  it  will  be  found 
that,  by  the  time  the  operation  is  completed  and  the  forceps  are  removed, 
few  of  the  vessels  bleed  and  require  ligature.  Thus,  a  great  deal  of 
time  is  saved  in  the  course  of  a  long  operation. 

In  severe  and  protracted  operations  such,  for  example,  as  amputation 
of  the  breast,  it  is  very  important  to  examine  the  whole  of  the  wound 
for  bleeding  points  just  before  the  sutures  are  inserted.  In  these  opera- 
tions the  blood  pressure  often  falls  very  low  while  the  axilla  is  being 
cleared  out  and  many  vessels  stop  bleeding  only  to  bleed  again  as  the 
patient  recovers.  Again,  when  an  operation  has  been  conducted  in  the 
Trendelenburg  position,  it  is  important  to  lower  the  patient  to  the  hori- 
zontal before  commencing  to  close  the  wound.  Unless  this  be  done, 
vessels  may  commence  bleeding  which  had  stopped  while  the  patient 
was  in  the  inverted  position,  and  serious  haemorrhage  may  result. 

Horsley's  Wax. — Sir  Victor  Horsley  has  introduced  an  aseptic  wax 
for  use  in  bleeding  from  bone,  which  can  be  applied  over  the  bleeding 
point,  so  as  to  close  the  hole  in  the  bone  from  which  the  blood  comes. 
The  composition  of  this  wax  is  :  Beeswax,  7  parts ;  almond  oil,  I  part ; 
and  salicylic  acid,  I  part.  When  not  in  use,  the  wax  is  kept  in  a  vessel  of 
i  in  20  carbolic  solution.  When  it  is  required  for  use,  a  small  piece  is 
pinched  off,  softened  by  rolling  it  between  the  fingers,  which,  of  course, 
should  be  aseptic,  and  then  pressed  well  into  the  part  of  the  bone  from 
which  the  blood  is  coming.  The  wax  does  not  give  rise  to  any  trouble  in 
the  healing  of  the  wound. 

Cold. — There  are  various  other  ways  in  which  bleeding  maybe  arrested, 
and  which  are  specially  applicable  to  oozing  from  small  vessels  or  capil- 
laries which  cannot  be  controlled  by  the  means  already  mentioned.  The 
chief  of  these  are  those  methods  that  bring  about  contraction  of  the  coats 
of  the  vessel,  especially  cold.  The  application  of  cold  to  the  skin 
over  a  bleeding  part  will  lead  to  contraction  of  the  cutaneous  vessels,  and 
reflexly  to  contraction  of  those  of  the  deeper  parts.  For  example,  in 
operations  about  the  mouth  or  lips,  such  as  those  for  cleft  palate  or  hare- 
lip, bleeding  can  often  be  quickly  arrested  by  douching  the  face  with  iced 


OPERATIONS  AND  THEIR  MANAGEMENT  in 

water,  or  should  that  fail,  by  the  application  of  ice  to  the  neighbourhood 
of  the  bleeding  part. 

Leiter's  tubes,  which  have  already  been  mentioned  in  connection 
with  inflammation  (see  p.  10),  are  very  effectual  in  checking  bleeding. 
For  example,  in  haemorrhage  from  the  urethral  mucous  membrane, 
due  to  injury  or  gonorrhoea,  a  very  efficient  plan  is  to  coil  Leiter's 
tubes  around  the  penis,  and  pass  a  stream  of  ice-cold  water  through 
them.  The  effect  of  the  cold  is  to  make  the  penis  contract,  and  therefore 
it  is  well  to  pass  a  straight  catheter  a  short  distance  up  the  urethra  before 
fixing  on  the  coil.  The  result  of  applying  cold  in  this  manner  is  that 
contraction  of  the  cutaneous  vessels  occurs  followed  by  contraction  of  the 
deeper-seated  ones,  and  if  this  be  kept  up  for  a  short  time  coagulation 
and  permanent  occlusion  of  the  bleeding  vessels  will  follow.  The  pre- 
cautions to  be  observed  in  using  these  coils  are  mentioned  on  p.  10. 

Heat. — Heat  is  almost  equally  efficacious  in  arresting  bleeding,  and 
douching  the  bleeding  part  with  hot  water  has  a  powerful  haemostatic 
effect.  The  temperature  of  the  water  should  range  between  110° 
and  120°  F.,  and  the  condition  for  which  it  is  chiefly  employed  is  post- 
partum  haemorrhage,  the  uterus  being  flooded  with  water  at  this 
temperature. 

Styptics. — Haemorrhage  may  also  be  arrested  by  producing  coagu- 
lation of  the  blood  as  it  escapes  from  the  vessel  by  means  of  styptics. 
It  is  useless  to  pour  the  styptic  solution  into  a  bleeding  wound  or  to  swab 
one  over  with  it.  The  bleeding  must  first  be  temporarily  arrested,  because 
the  clot  produced  by  the  styptic  must  form  actually  in  the  orifice  of  the 
bleeding  vessel  and  not  on  the  surface  of  the  wound  if  the  method  is  to  be 
effectual.  The  bleeding  area  should  be  compressed  in  some  suitable 
manner,  so  that  the  bleeding  is  temporarily  arrested  ;  it  is  then  painted 
over  with  the  styptic  solution,  and  the  pressure  is  maintained  for  a  short 
time  in  order  to  keep  the  wound  from  bleeding,  and  to  give  the  styptic 
time  to  act.  The  styptics  usually  employed  are  the  liquor  ferri  perchlor. 
B. P.,  the  liquor  ferri  perchlor.  fort,  mixed  with  an  equal  part  of  glycerine, 
or  tincture  of  matico.  Perchloride  of  iron  is  a  powerful  styptic,  but  it 
often  causes  a  slough  on  the  surface  of  the  wound,  which  is  a  source  of 
danger  in  the  mouth  or  in  any  part  where  sepsis  subsequently  occurs, 
as  septic  micro-organisms  are  likely  to  grow  in  it.  Adrenalin  chloride 
(i  in  1000)  is  not  open  to  this  serious  objection,  and  is  a  very  efficient 
styptic  when  the  haemorrhage  comes  from  small  arteries.  It  is  not  of  use 
in  bleeding  from  veins ;  for  example,  it  is  useless  in  cases  of  haemorrhage 
from  the  venous  channels  of  the  diploe.  Lactate  of  calcium  has  been 
employed  recently  in  the  treatment  of  haemorrhage,  more  especially  as 
a  prophylactic  before  an  operation  in  which  severe  haemorrhage  is  likely 
to  be  encountered,  or  when  the  coagulability  of  the  blood  is  imperfect. 
It  should  be  given  for  several  days  before  the  operation  in  doses  of  five 
to  ten  grains  three  times  a  day,  or  in  single  doses  of  thirty  to  sixty  grains 


H2  WOUNDS 

given  by  the  rectum  some  hours  before  the  operation.  Opinions  are 
divided  as  to  its  merits. 

Symptoms  of  Serious  Loss  of  Blood.— So  much  blood  may  be  lost, 
either  from  continuous  oozing  from  the  vessels,  or  from  its  sudden  escape 
from  some  large  trunk,  that  the  patient's  life  is  endangered.  Bleeding 
may  also  occur  under  a  dressing,  or  into  the  abdomen  in  cases  of  abdominal 
operations,  after  the  patient  has  been  removed  to  bed,  and  it  is  necessary 
that  the  surgeon  should  recognise  the  symptoms  of  serious  loss  of  blood. 
They  are  pallor,  a  rapid,  soft,  and  feeble  pulse,  gasping  or  sighing  respira- 
tion from  imperfect  oxygenation  of  the  tissues,  and  a  tendency  to  twitch- 
ing of  the  muscles ;  when  the  haemorrhage  is  rapid  the  patient  soon  loses 
consciousness.  The  most  typical  sign  is  restlessness ;  the  patient  gasps 
for  air,  throws  himself  about,  and  uncovers  his  chest  in  the  endeavour  to 
get  more  air  into  his  lungs. 

Transfusion  and  Infusion. — These  symptoms  should  at  once  lead  the 
surgeon  to  assume  that  serious  bleeding  is  going  on,  and  the  dressing 
should  therefore  be  removed  immediately,  and  the  wound  opened  up 
if  necessary,  with  the  view  of  securing  the  bleeding  point.  The  patient's 
condition  may  be  so  bad  that  it  is  not  advisable  to  search  for  the  bleeding 
point,  lest  he  die  during  the  attempt  to  find  it,  and  in  such  a  case,  tem- 
porary pressure  must  be  resorted  to.  In  any  case,  measures  must  be 
taken  to  restore  the  volume  of  fluid  in  the  blood-vessels  by  means  of 
infusion  if  the  loss  of  blood  be  serious.  The  fluid  used  for  infusion  may 
either  be  blood,  pure,  mixed  with  phosphate  of  soda,  or  defibrinated — in 
which  case  the  operation  is  termed  transfusion;  or  an  indifferent  fluid, 
such  as  normal  saline  solution — when  it  should  be  called  infusion.  The 
use  of  blood,  either  pure  or  mixed  with  phosphate  of  soda,  has  been  found 
unsatisfactory,  since  the  red  blood  corpuscles  introduced  have  compara- 
tively little  effect  as  carriers  of  oxygen,  and  there  is  great  difficulty  and 
risk  in  introducing  pure  blood,  chiefly  owing  to  the  formation  of  coagula 
in  the  instruments,  or  the  detachment  of  coagula  from  them  giving  rise 
to  pulmonary  embolism.  Even  defibrinated  blood  is  not  free  from  this 
last  objection.  On  the  other  hand,  indifferent  fluids  answer  the  purpose 
of  giving  the  heart  enough  fluid  to  contract  upon,  and  enabling  it  to  drive 
what  corpuscles  remain  through  the  circulation,  thus  keeping  the  patient 
alive  until  fresh  blood  has  been  manufactured,  without  exposing  him  to 
the  risks  of  the  other  method.  We  shall  not  describe  the  technique  of 
transfusion  with  blood. 

Saline  Infusion. — The  most  common  material  for  infusion  is  the 
ordinary  salt  solution  used  in  physiological  work,  that  is  to  say,  a  075  per 
cent,  solution  of  common  salt.  In  practice,  this  is  roughly  about  a  tea- 
spoonful  of  common  salt  to  the  pint  of  water.  The  solution  should  be 
boiled  and  allowed  to  cool  down  to  100°  F.  by  standing  it  under  cover  or  in 
ice.  In  cases  of  emergency,  however,  it  is  not  always  easy  to  get  boiled 
water,  and  too  much  time  is  wasted  if  the  water  has  to  be  boiled  and 


OPERATIONS  AND  THEIR  MANAGEMENT  113 

cooled,  and  therefore  it  is  necessary  to  risk  the  introduction  of  organisms 
by  mixing  the  water  from  the  kitchen  boiler  with  sufficient  ice  or  cold 
water  to  reduce  the  temperature  to  the  required  degree.  It  is  a  common 
practice  to  mix  ordinary  table  salt  with  sterilised  water  in  the  proper 
proportions  and  to  look  upon  this  as  sterilised  saline  solution.  The  salt 
is  more  likely  to  contain  organisms  than  is  tap  water  and  must  always 
be  sterilised  by  boiling  before  use.  Even  in  cases  of  emergency  it  is 
possible  to  boil  the  required  amount  of  salt  in  a  small  quantity  of  water 
and  then  dilute  it  as  above. 

In  introducing  the  saline  solution  a  vein  is  exposed  (preferably  the 
median  basilic),  a  double  ligature  of  cagut  is  passed  around  it,  the  loop 
divided  in  the  centre,  and  the  two  threads  separated  from  one  another.  An 
oblique  cut  is  then  made  through  about  half  the  calibre  of  the  vessel  between 
the  two  threads,  and  the  nozzle  of  a  suitable  canula  is  inserted  into  the 
opening  and  tied  in  by  the  upper  of  the  two  threads  of  the  double  liga- 
ture, the  vein  also  being  ligatured  below  by  the  lower  thread,  so  that  the 
blood  does  not  escape  from  the  distal  end  (see  Fig.  30).  There  may  be 
difficulty  in  making  the  vein  prominent  when  the  circulation  is  feeble.  If 
it  cannot  be  seen  by  lightly  constricting  the  upper  arm,  the  best  plan  is  to 
make  a  transverse  cut  across  the  direction  of  the  vessel  down  to  the  deep 
fascia  ;  the  divided  ends  of  the  vein  can  then  be  seen,  the  distal  end  liga- 
tured, the  proximal  grasped  with  forceps,  and  the  canula  introduced  and 
tied  in.  Before  the  canula  is  inserted,  a  piece  of  india-rubber  tubing  is 
attached  to  it,  and  to  the  other  end  of  this  is  fitted  a  sterilised  glass 
funnel  or  the  barrel  of  a  glass  syringe  from  which  the  piston  has  been 
removed.  The  whole  of  this  apparatus  must  be  sterilised  by  boiling 
previous  to  use,  filled  completely  with  salt  solution  so  as  to  expel  all  the 
air,  and  clamped  with  a  suitable  clip.  Care  must  be  taken  that  no  air  gets 
in  at  any  time.  The  funnel  is  held  from  two  to  three  feet  above  the  level 
of  the  patient,  the  clamp  is  opened,  and  the  fluid  allowed  to  flow  gradually 
into  the  vein,  care  being  taken  to  see  that  the  funnel  is  replenished 
before  the  fluid  in  it  has  quite  run  away,  as  otherwise  air  may  find  access 
to  the  tube  and  so  to  the  circulation.  The  rapidity  of  the  flow  can  be 
regulated  by  raising  the  funnel  above  the  level  of  the  heart ;  this  can  be 
done  better  by  means  of  a  funnel  than  if  the  saline  solution  were  injected 
by  means  of  a  syringe.  The  amount  of  fluid  introduced  should  be  from 
two  to  five  pints,  and  the  condition  of  the  patient  has  to  be  carefully 
watched  during  its  introduction.  If  it  enter  too  rapidly,  the  fluid  that 
is  driven  from  the  heart  into  the  lungs  may  consist  of  pure  salt  solution, 
and  consequently  signs  of  imperfect  aeration  of  the  blood  become  evident ; 
the  respiration  becomes  embarrassed,  and  twitchings  and  restless  move- 
ments occur,  and  the  patient  may  die  at  once.  If  these  s}Tmptc  ms  occur,  the 
tube  should  be  clamped  and  the  further  introduction  of  fluid  deferred  until 
the  dangerous  symptoms  have  passed  off.  About  half-an-hour  should  be 
taken  to  introduce  two  pints  of  the  fluid,  and  it  is  well  to  stop  occasionally 


II4  WOUNDS 

to  allow  the  blood  to  be  mixed  thoroughly  with  the  saline  solution.     The 
original  source  of  bleeding  must  be  controlled  in  all  cases   either   by 


B  C 

FIG.  30. — INTRA-VENOUS  INFUSION. — (A)  The  vein  has  been  exposed  and  its 
sheath  opened  ;  two  ligatures  have  been  passed  beneath  it,  the  distal  one  of  which 
has  been  tied,  the  upper  one  being  left  around  the  vein  at  the  opposite  extremity  of 
the  wound.  The  wall  of  the  vein  has  been  pinched  up  with  a  pair  of  fine  forceps  and 
a  V-shaped  incision  is  about  to  be  made  into  the  wall  of  the  vein  with  a  pair  of 
scissors.  (B)  The  incision  has  been  made,  the  forceps  retaining  their  original  hold 
upon  the  wall  of  the  vein,  which  has  been  lifted  up  so.  as  to  expose  and  stretch  the 
opening.  (C)  A  canula  has  been  passed  into  the  opening  in  the  vein  and  along  its 
lumen  for  a  short  distance,  its  position  beneath  the  skin  at  the  upper  end  of  the 
wound  being  indicated  by  the  dotted  lines.  The  second  ligature  has  been  tied  in  a 
single  knot  around  the  canula  and  is  ready  to  occlude  the  vein  when  the  canula 
is  withdrawn. 


ligature  or  pressure,  otherwise  the  rise  in  blood  pressure  following  the 
infusion  may  start  a  fresh  and  fatal  haemorrhage.  It  may  be  necessary 
to  repeat  the  infusion  in  an  hour  or  so  when  much  blood  has  been  lost. 


OPERATIONS  AND  THEIR   MANAGEMENT  115 

Unless  there  be  also  great  shock,  however,  one  infusion  is  usually  sufficient 
to  tide  the  patient  over  until  a  sufficient  quantity  of  fresh  corpuscles  has 
been  manufactured. 

When  the  condition  is  less  urgent,  it  is  better  to  allow  the  fluid  to  be 
absorbed  rather  than  to  inject  it  directly  into  the  circulation,  and  this 
may  be  done  by  injecting  the  salt  solution  either  into  the  rectum  or  under 
the  mamma.  In  the  latter  case  from  fifteen  to  twenty  ounces  can 
be  introduced  on  each  side.  Absorption  will  be  then  so  regulated  by  the 
body  that  too  rapid  dilution  of  the  blood  will  not  take  place. 

An  excellent  plan,  especially  when  there  has  also  been  shock,  is  to 
introduce  the  salt  solution  very  slowly  into  the  rectum.  An  irrigator  pre- 
ferably surrounded  by  a  hot-water  jacket  is  filled  with  salt  solution  at 


FIG.  31. — DIAGRAM  TO  ILLUSTRATE  THE  METHOD  OF  CONTINUOUS  RECTAL  IN- 
FUSION.— The  reservoir  is  shown  supported  upon  a  stand  slightly  raised  above  the 
patient's  pelvis,  it  is  connected  by  a  length  of  rubber  tubing  with  a  rectal  tube  made 
of  some  unyielding  material  or  of  stout  india-rubber.  The  rate  of  flow  can  be  seen 
by  the  aid  of  the  glass  dropping  tube  (a)  shown  on  the  right  of  the  apparatus. 

110°  F.  and  fixed  from  six  to  twelve  inches  above  the  level  of  the  anus, 
the  outflow  through  the  tube  being  regulated  so  that  the  fluid  only  comes 
out  drop  by  drop,  about  a  pint  an  hour.  The  tube  from  the  irrigator  is 
attached  to  a  rubber  catheter  introduced  well  into  the  rectum  and  left 
there.  The  advantage  of  this  plan  is  that  every  drop  of  the  fluid  is  absorbed 
and  there  is  no  distension  of  the  bowel  which  would  lead  to  expulsion  or 
escape  of  the  solution,  while  the  administration  may  be  continued  for 
hours. 

Many  variations  of  this  method  have  been  introduced.  In  one  form  the 
saline  solution  is  kept  at  a  constant  temperature  by  means  of  a  '  Thermos ' 
flask;  in  another  by  an  electrical  device.  In  the  latter  apparatus  the 
receiver  is  filled  with  salt  solution  at  a  temperature  slightly  above  that 
of  the  body  and  a  connection  made  with  the  house  current.  The  heating 
device  is  so  arranged  that  the  temperature  at  which  the  saline  leaves  the 
container  remains  constant.  It  must  be  remembered,  however,  that  a 
considerable  amount  of  heat  is  lost  in  the  passage  of  the  fluid  through 

I  2 


n6 


WOUNDS 


the  pipe  which  leads  into  the  rectum,  and  it  is  always  safer  to  conduct 
a  few  experiments  with  the  apparatus  and  the  exact  length  of  tubing 
to  be  employed  before  actually  using  it. 

If  no  such  apparatus  be  at  hand,  an  ordinary  douche  can  may  be 
employed.  This  should  be  provided  with  a  long  delivery  tube,  which 
is  coiled  in  a  pail  of  hot  water,  before  it  is  led  into  the  bowel.  The 
irrigator  is  filled  with  warm  saline  solution,  which  is  kept  hot  in  the  tube 

by  the  water  in  the  pail.  The  temperature 
of  the  water  in  the  pail  is  kept  up  by 
repeated  additions  of  boiling  water.  It 
should  be  as  hot  as  the  hand  can  com- 
fortably bear.  In  another  form  of  appa- 
ratus the  slow  absorption  of  the  saline 
solution  is  obtained  by  keeping  the 
surface  of  the  fluid  in  the  irrigator  a  very 
short  distance  (two  or  three  inches)  above 
the  rectum.  The  rate  of  flow  can  be 

i     4  regulated    by    raising     or    lowering    the 

/     jj  |  irrigator.      In  this  form  of  apparatus  the 

j  delivery  tube  should  be  as  short  and  as 

/wide  as  possible  so  as  to  permit  the  passage 
ft  of  flatus. 

J  .     \    I  In  all  these  forms  of  apparatus  care 

^  is  necessary  to  see  that  the  flow  is  not 

impeded  by  kinking  of  or  pressure  upon 
the  tube  into  the  rectum.  Two  simple 
devices  to  obviate  this  inconvenience  are : 
to  employ  flexible  gas-tubing  at  the  vul- 
nerable points,  or  to  lead  the  rubber- 
tubing  through  fibre-tubing  of  suitable 
size ;  both  withstand  pressure  well. 

After    an    operation   blood     may    be 
found   oozing   through  the  dressing.      If 

this  be  not  excessive,  the  bandage  should  be  moistened  with  i  in  20 
carbolic  solution  and  some  wet  gauze  applied  outside.  If,  however, 
the  oozing  continue  and  the  wound  become  increasingly  painful,  or 
if  the  patient  show  signs  of  severe  loss  of  blood,  the  dressing  must  be 
removed  and  the  condition  of  affairs  investigated.  It  will  often  happen 
on  exposing  the  wound  that  no  bleeding  can  be  seen  coming  from  between 
its  margins  or  through  the  drainage  tube,  if  one  has  been  used ;  should  this 
be  the  case,  the  wound  should  simply  be  re-dressed.  The  explanation 
is  that  the  blood  which  was  poured  out  during  the  first  few  hours  after 
the  operation  has  percolated  through  the  dressing  and  given  the  false 
impression  of  a  continuous  haemorrhage.  If  it  be  obvious,  however,  that 
haemorrhage  is  still  going  on,  some  at  least  of  the  stitches  must  be  un- 


Fio.  32.  —  ELECTRICAL  APPARATUS 
for  maintaining  the  temperature  of 
saline  solution  for  continuous  rectal 
infusion. 


OPERATIONS  AND  THEIR  MANAGEMENT  117 

done.  It  will  very  often  be  found  that  the  haemorrhage  is  coming  from  a 
superficial  vessel  in  the  skin  itself  and,  as  in  these  cases  the  blood  escapes 
through  the  part  of  the  wound  nearest  to  the  bleeding  vessel,  it  is  often  only 
necessary  to  take  out  one  or  two  stitches.  If,  however,  the  whole  wound 
be  distended  with  blood-clot,  it  is  better  to  give  an  anaesthetic,  open  it  up, 
and  clear  out  the  clots.  This  procedure  alone  often  suffices  to  check  the 
haemorrhage.  If  a  bleeding  point  be  found  it  must  be  ligatured  ;  if  the 
haemorrhage  be  obviously  due  to  general  oozing,  the  wound  should  be 
carefully  packed  with  gauze  and  a  firm  bandage  applied. 

It  is  very  important  to  act  with  due  deliberation  and  with  full  anti- 
septic precautions  in  these  cases.  Although  the  case  is  urgent,  the  few 
minutes  necessary  for  sterilising  instruments,  etc.,  is  rarely  of  much 
moment,  while  any  omission  to  do  this  may  lead  to  grave  sepsis. 

SHOCK. 

There  are  several  factors  in  the  complex  of  symptoms  known  as 
shock,  and  this  must  be  borne  in  mind  in  dealing  with  patients  who 
are  subjected  to  a  surgical  operation.  In  the  first  place  there  is  the 
simple  reflex  cardiac  inhibition  seen  when  a  patient  faints  as  the  result  of 
a  blow.  This  is  often  seen  in  the  course  of  a  surgical  operation  involving 
traction  or  pressure  upon  large  nerves.  The  patient  becomes  pale,  has 
an  almost  imperceptible  pulse,  while  the  breathing  is  rapid  and  shallow 
and  the  whole  muscular  system  toneless  and  flaccid;  sweating  is  often 
observed  in  addition.  This  condition  usually  passes  off  fairly  rapidly, 
but  if  the  stimulus  be  prolonged,  the  condition  may  become  more  serious, 
and  may  be  an  important  contributory  factor  in  bringing  about  an 
immediately  fatal  result. 

Death  occurs  partly  from  the  severity  of  the  shock  (the  nerve  centres 
being  unable  to  regain  their  power)  and  partly  from  its  duration.  When 
the  depression  is  long  continued,  and  the  circulation  consequently  ex- 
tremely feeble,  clots  are  apt  to  form  in  the  pulmonary  artery,  and  recovery 
is  then  out  of  the  question.  In  addition  to  the  cardiac  inhibition  there  is  a 
lowering  of  the  blood  pressure.  There  has  been  much  controversy  as  to 
the  pathology  of  this  condition,  but  the  balance  of  evidence  points  to  its 
being  due  to  general  dilatation  of  the  peripheral  vessels.  Post-mortem 
observations  are  of  little  value,  inasmuch  as  after  death  the  arteries  are 
always  found  practically  empty.  The  fall  of  blood  pressure  is  accentuated 
by  actual  loss  of  blood  from  haemorrhage  and  possibly,  according  to  some 
experimenters,  to  inspissation  of  the  blood  itself. 

Shock  also  has  an  effect  upon  the  higher  cerebral  centres,  shown  by  the 
prolonged  effect  of  severe  operations  upon  the  nervous  stability.  It  is  a 
matter  of  common  observation  that  after  operations,  especially  upon  the 
sexual  organs,  the  patient  will  often  exhibit  unwonted  emotional  pheno- 
mena long  after  the  operation.  For  example,  a  woman  will  often  be 


n8       .  WOUNDS 

abnormally  irritable  or  at  times  hysterical  for  twelve  months  after  a 
hysterectomy,  although  recovery  from  the  operation  seems  to  have  been 
complete.  Even  after  less  severe  operations  the  condition  of  mental 
lassitude  and  irritability  is  often  well  marked,  and  patients  will  be  content 
to  lie  in  bed  doing  nothing  when  they  might  be  expected  to  read,  write, 
or  otherwise  amuse  themselves. 

The  effect  of  the  anaesthetic  must  be  also  borne  in  mind.  All  anae- 
sthetics are  protoplasmic  poisons,  and  in  some  cases  microscopical  changes 
can  be  actually  observed  in  the  tissues  after  prolonged  anaesthesia,  for 
example,  fatty  degeneration  of  the  liver  cells  and  disappearance  of  the 
Nissl  granules  of  the  cerebral  cortex.  Moreover,  during  anaesthesia  the 
loss  of  heat  from  the  skin  is  not  compensated  for  by  the  action  of  the 
thermal  centres  and  the  patient  is  therefore  extremely  sensitive  to  cold. 
Under  normal  conditions,  lowering  of  the  temperature  leads  to  an  increase 
in  the  output  of  carbonic  acid,  but  in  an  anaesthetised  condition  the  reverse 
obtains  and  the  carbonic  acid  output  is  actually  diminished  as  the 
temperature  falls.  This  point,  which  has  been  investigated  experimentally, 
indicates  the  importance  of  warmth  during  the  administration  of  an 
anaesthetic.  The  degree  of  shock  depends  on  the  part  of  the  body  operated 
upon  ;  for  example,  a  long  time  may  be  spent  in  repairing  a  badly  united 
or  un-united  fracture  of  the  extremities  without  producing  anything 
like  the  amount  of  shock  that  a  much  shorter  and  gentler  operation  on 
the  abdominal  cavity  will  cause,  especially  if  the  peritoneum  be  inflamed. 
Loss  of  blood  also  increases  the  risk  of  shock,  which  is  therefore  more 
marked  in  operations  in  which  there  is  severe  haemorrhage. 

SYMPTOMS. — If  shock  comes  on  during  an  operation,  its  presence 
is  indicated  by  increasing  pallor  and  weakness  of  the  pulse,  which  becomes 
rapid,  dicrotic,  and  sometimes  irregular.  The  pupils  become  dilated,  the 
reflexes  are  slow,  there  is  often  sweating  about  the  forehead,  and  the  skin 
becomes  cold.  After  the  operation  the  pulse  remains  bad  and  the  patient 
cold,  and,  though  consciousness  may  be  recovered  to  some  extent,  the 
senses  are  dull.  When  severe  shock  is  established  it  is  difficult  to  over- 
come, and  therefore  it  is  very  important  to  take  measures  beforehand  to 
avoid  or  diminish  it  as  much  as  possible. 

TREATMENT.— («)  Prophylaxis.— We  have  already  referred  to 
several  points  in  the  preparation  of  the  patient  which  are  important  in 
connection  with  the  question  of  shock,  such  as  his  frame  of  mind,  a  good 
night's  rest  previous  to  operation,  and  the  administration  of  food  ;  of 
special  importance  is  a  nutrient  enema  half-an-hour  before  the  hour  fixed 
for  the  operation. 

An  essential  precautionary  point  is  to  keep  up  the  body  temperature. 
The  temperature  of  the  operation  room  should  be  maintained  at  65°  to 
85°  F.  This,  however,  is  not  of  itself  sufficient  in  bad  cases,  and  the  best  plan 
is  to  have  the  table  on  which  the  patient  is  lying  kept  at  100°  to  105°  F. 
by  means  of  hot  water.  In  some  operating  tables  this  is  accomplished 


OPERATIONS  AND  THEIR  MANAGEMENT  119 

by  having  the  top  of  the  table  composed  of  a  series  of  tubes  through 
which  hot  water  circulates,  but  this  necessitates  a  special  table.  An 
equally  good  plan  is  to  have  a  large  copper  tray  about  six  inches  deep 
and  five  feet  in  length,  with  a  metal  top,  and  tubes  at  the  ends  for  the  en- 
trance and  exit  of  hot  water,  which  is  kept  circulating  through  it  during 
the  operation.  Where  this  is  not  available,  its  place  may  be  supplied  by  a 
water-bed  or  large  water-pillow  filled  with  water  at  a  temperature  of 
110°  F.  The  latter  is  frequently  used  in  operations  upon  children, 
although  it  is  not  so  steady  as  the  hot-water  table.  Whenever  there  is 
any  chance  of  the  flannel  covering  the  hot-water  bottle  or  pillow  becoming 
wet  during  the  operation,  mackintosh  should  be  interposed  between  this 
and  the  patient's  skin  ;  otherwise  the  wet  flannel  will  scald  the  patient. 
This  is  not  uncommon  in  operations  upon  small  children  lying  upon 
india-rubber  hot-water  bags.  Hot-water  bottles  are,  however,  always 
dangerous  and  should  never  be  used  when  it  is  possible  to  keep  the  patient's 
temperature  up  in  any  other  way. 

The  table  should  be  covered  with  warm  blankets,  on  which  the  patient 
lies,  and  the  aseptic  towels  around  the  area  of  operation  (see  Chap.  V.)  are 
wrung  out  of  hot  lotion  and  changed  at  intervals.  When  the  arrangements 
above  described  are  not  available,  the  room  should  be  kept  as  warm  as 
one  can  work  in.  All  lotions  used  during  the  operation  should  be  at  about 
a  temperature  of  100°  F.  If  coils  of  intestine  escape  in  abdominal 
operations  they  should  be  replaced  at  once,  or  should  be  covered  with 
warm  aseptic  cloths  or  sponges  frequently  renewed,  if  it  be  necessary  to 
keep  them  outside  the  body.  In  infants,  an  incision  large  enough  to 
admit  only  two  fingers  is  relatively  extensive  compared  with  the  size 
of  the  abdomen  and  it  often  happens  that  a  sudden  straining  movement 
will  eject  practically  the  whole  of  the  small  intestines.  These  can  be 
satisfactorily  protected  from  injury  and  kept  warm  by  allowing  a  constant 
stream  of  hot  saline  solution  to  run  over  them  either  from  an  irrigator  or 
poured  out  of  a  jug. 

Rapidity  of  operation  is  also  important  in  cases  in  which  shock  is  likely 
to  occur.  The  steps  of  the  operation  should  be  carefully  planned  before- 
hand, and  all  necessary  preparations  made  before  the  anaesthetic  is 
administered,  so  that  no  time  is  lost  afterwards.  When  it  is  important 
to  reduce  the  time  that  the  patient  is  under  the  anaesthetic  to  a  minimum, 
all  preliminaries,  such  as  shaving,  purification  of  the  skin,  arrangement  of 
aseptic  towels,  etc.,  should  be  carried  out  before  the  anaesthetic  is  com- 
menced. Loss  of  blood  should  also  be  avoided  as  far  as  possible.  The 
management  of  the  anaesthetic  has  been  specially  referred  to  in  the  section 
dealing  with  Anaesthetics. 

The  administration  of  strychnine  before  the  commencement  of  the 
operation  is  of  great  value  in  the  prevention  or  diminution  of  shock. 
In  an  adult,  a  thirtieth  of  a  gram  should  be  injected  subcutaneously  just 
before  the  operation,  or  while  the  patient  is  being  placed  under  the 


120  WOUNDS 

anaesthetic ;  this  may  be  repeated  more  than  once  during  the  operation, 
if  the  pulse  begins  to  fail ;  even  larger  doses  may  be  administered.  It 
is  very  important  to  give  the  strychnine  before  the  shock  has  set  in,  for 
when  shock  is  once  established  remedies  are  of  little  avail,  and  recovery 
mainly  depends  on  the  patient's  recuperative  power. 

Infusion  of  saline  solution  into  the  axilla  is  also  of  great  value, 
especially  in  young  children.  The  needle  should  be  inserted  before  the 
operation  incision  is  made,  and  an  assistant  should  inform  the  surgeon 
of  the  progress  of  the  infusion,  reporting  when  each  ounce  of  saline 
solution  has  run  in.  For  children  under  three  years  one  to  three  ounces  is 
usually  sufficient.  When  this  method  of  infusion  is  practised,  the  whole 
of  the  fluid  is  not  absorbed  at  the  close  of  the  operation,  although  sufficient 
has  entered  into  the  circulation  to  maintain  the  blood  pressure.  This 
probably  accounts  for  the  fact  that  the  severe  collapse,  which  otherwise 
so  often  comes  on  several  hours  after  the  operation  has  been  concluded, 
does  not  occur. 

In  adults  a  method  of  auto-infusion  has  been  suggested,  and  in  opera- 
tions such  as  amputation  at  the  hip-joint  or  excision  of  the  scapula  is 
often  of  great  value.  The  limbs  which  are  not  being  operated  on  have  a 
tourniquet  applied  to  them  as  high  up  as  possible  without  of  course  any 
preliminary  emptying  of  the  veins.  In  this  way  a  large  amount  of  blood 
is  segregated  from  the  circulation  and  does  not  become  saturated  with 
the  anaesthetic.  At  the  close  of  the  operation,  or  whenever  necessary,  the 
tourniquets  are  slowly  removed  and  the  blood  is  allowed  to  enter  the 
circulation.  An  ingenious  pneumatic  suit  has  also  been  devised  by  Crile, 
especially  for  cranial  operations.  The  object  of  this  is  to  maintain  the 
blood  pressure  by  diminishing  the  capacity  of  the  whole  vascular  system 
by  exerting  uniform  pressure  on  the  trunk  and  the  limbs.  A  similar 
effect  may  be  obtained  by  bandaging  the  limbs  from  the  extremities 
towards  the  trunk  with  either  an  india-rubber  bandage  somewhat 
loosely  or  a  crepe  one  firmly  applied. 

(b)  When  established. — When  shock  is  established,  vigorous  measures 
must  be  adopted  to  combat  it.  In  the  first  place,  warmth  is  of  the  highest 
importance  ;  the  patient  should  be  wrapped  up  in  warm  blankets,  outside 
which  hot  bottles  are  placed ;  benefit  will  also  be  obtained  by  chafing  the 
extremities  and  the  abdomen.  He  should  be  put  to  bed  as  rapidly  as 
possible  and  laid  quite  flat,  with  only  a  thin  bolster  beneath  the  head, 
the  foot  of  the  bed  being  raised  about  six  inches  so  as  to  favour  the  flow 
of  blood  to  the  brain,  and  he  should  be  kept  as  still  as  possible  so  as 
not  to  exhaust  the  heart.  A  useful  measure  is  to  cover  the  patient  with 
a  blanket,  place  a  large  cage  or  cradle  outside  this  and  hang  electric 
lights  from  the  top  bar  of  the  cradle,  covering  the  whole  with  blankets. 

Free  stimulation  is  also  important ;  perhaps  the  most  rapid 
stimuant  is  ether  injected  subcutaneously  in  doses  of  from  twenty  to 
thirty  minims.  The  point  of  the  needle  used  for  injecting  the  ether 


OPERATIONS  AND  THEIR  MANAGEMENT  121 

should  be  buried  in  the  muscle,  for  sloughing  of  the  skin  may  occur 
if  a  large  quantity  be  injected  subcutaneously.  The  ether  may  be 
repeated  in  fifteen  or  twenty  minutes  if  necessary,  and  brandy  also  may 
be  injected  in  the  same  quantity  still  more  frequently.  Half  a  drachm 
of  a  twenty-per-cent.  solution  of  camphor  in  sterilised  almond  oil 
may  be  injected  hypodermically.  A  hot  nutrient  enema  containing 
half  an  ounce  or  more  of  brandy  and  two  ounces  of  strong  coffee  should 
also  be  administered,  and  it  may  be  advisable  to  give  this  during  the 
course  of  the  operation  if  signs  of  severe  shock  appear.  Strychnine  and 
di°italine  are  also  valuable,  a  thirtieth  of  a  grain  of  strychnine  (or  a  sixtieth 
if  it  has  been  already  twice  administered  during  the  course  of  the  operation) , 
combined  with  a  hundredth  of  a  grain  of  digitaline  being  given  and 
repeated  every  hour  if  necessary  for  three  or  four  doses.  Adrenalin  is 
also  much  used  at  the  present  time  in  these  cases,  and  pituitary 
extract  has  recently  been  found  of  value.  The  latter  drug  must, 
however,  be  given  with  caution  and  not  in  old  people,  as  the  blood 
accumulates  in  the  lungs,  and  actual  haemorrhage  may  occur  there. 

Some  authorities  lay  stress  upon  the  value  of  saline  infusion,  which 
is  performed  as  described  on  p.  112.  The  effect  upon  the  pulse  and  the 
breathing  should  be  carefully  watched,  and  the  injection  continued  until 
the  pulse  becomes  full,  regular,  and  approaching  its  normal  rate.  For 
this  purpose  at  least  two  or  three  pints  of  the  saline  solution  will  be 
required. 

When  the  infusion  is  done  chiefly  for  loss  of  blood,  the  results  are 
often  striking,  one  injection  being  sufficient  to  tide  the  patient  over  his 
danger.  When,  however,  it  is  performed  for  pure  shock,  the  effect, 
although  good,  is  often  transient,  and  the  symptoms  of  shock  begin  to 
reassert  themselves  after  the  lapse  of  from  a  half  to  three  hours,  and  it 
may  be  necessary  to  repeat  the  injection  even  a  third  or  fourth  time,  the 
canula  being  kept  in  situ  in  the  intervals  between  the  injections.  This, 
however,  gives  rise  to  such  an  extreme  dilution  of  the  blood  as  to  produce 
imperfect  aeration  in  the  lungs,  and  sometimes  severe  dyspnoea  may 
result ;  if  this  be  the  case,  the  infusion  must  be  stopped,  and  rectal 
injections  and  stimulants  substituted.  Infusion  as  a  treatment  for 
shock,  although  worth  a  trial  in  bad  cases,  has  not  proved  so  satis- 
factory in  our  hands  as  the  writings  of  some  surgeons  might  lead  one 
to  expect ;  in  a  case  of  pure  shock  the  further  dilution  of  the  blood 
can  hardly  be  expected  to  aid  the  recovery  of  the  nerve  centres. 
A  better  method  is  to  inject  the  saline  solution  into  the  cellular 
tissue  of  the  axilla  (see  p.  120),  and  the  advantage  of  this  is  that 
dilution  of  the  blood  does  not  occur  so  rapidly;  half  a  pint  or  more 
of  the  saline  solution  should  be  injected  into  the  areolar  tissue  of  the 
axilla  at  once,  and  repeated  in  an  hour  if  necessary.  Still  better  is  the 
infusion  into  the  rectum  drop  by  drop,  as  described  on  p.  115,  as  soon 
as  the  patient  has  been  put  back  to  bed. 


122  WOUNDS 

These  methods  are  the  most  suitable  ones  to  employ  when  the 
shock  has  not  yet  become  profound,  and,  when  shock  is  apprehended, 
careful  watch  should  always  be  kept  for  the  early  symptoms,  so  that 
one  of  these  remedies  may  be  employed  in  time.  When  a  nutrient 
enema  has  been  administered,  half  an  hour  or  an  hour  must,  however, 
be  allowed  to  elapse  before  the  saline  solution  is  injected.  In  pure 
shock  stimulants  are  of  much  importance,  but  when  there  is  much 
haemorrhage  the  saline  solution  is  of  more  immediate  value. 

Influence  of  Pain  on  Shock. — A  difficult,  but  at  the  same  time  an 
important,  question  is  how  far  severe  pain  keeps  up  the  shock,  and  to 
what  extent  anodynes  may  be  administered  with  the  view  of  relieving 
it.  There  can  be  hardly  any  doubt  that  prolonged  pain  will  cause 
exhaustion  of  the  nervous  system,  and  thus  prolong  or  even  set  up 
shock,  and  it  is  therefore  of  importance  to  diminish  it  if  possible.  An 
injection  of  morphine  before  the  patient  comes  round  from  the  anaesthetic 
may  diminish  shock  to  some  extent,  but  when  once  shock  is  established 
morphine  alone  is  apt  to  cause  a  great  deal  of  depression.  The  addition 
of  atropine  to  some  extent  removes  this  objection,  and  therefore  a  sub- 
cutaneous injection  of  an  eighth  to  a  quarter  of  a  grain  of  morphine 
with  T^th  of  a  grain  of  atropine  is  advisable  when  there  is  much  pain. 
It  is  better  to  give  a  small  dose  and  repeat  it  than  to  give  one  large  dose. 

ENTRY   OF  AIR  INTO    VEINS. 

This  accident  is  especially  apt  to  happen  in  operations  about  the  root 
of  the  neck  on  account  of  the  proximity  of  the  heart,  and  the  fact  that 
the  veins  pass  through  rigid  openings  in  the  deep  fascia  of  the  neck.  If 
a  vein  be  opened  in  these  operations  and  not  immediately  occluded,  air 
is  apt  to  be  sucked  in  through  the  proximal  end  of  the  vessel  during 
inspiration,  and  this  will  give  rise  to  very  serious  embarrassment  of  the 
pulmonary  circulation.  The  right  side  of  the  heart  becomes  full  of 
blood,  which  is  frothy  from  admixture  with  air  and  not  readily  driven 
on  into  the  pulmonary  artery,  and  immediate  death  may  be  the  result. 
When  only  a  small  quantity  of  air  enters,  death  does  not  occur  so  suddenly. 
The  patient  then  becomes  rapidly  cyanosed,  with  quick,  deep,  almost 
convulsive  respiratory  movements  as  if  there  were  laryngeal  obstruction  ; 
there  is,  however,  no  stridor  and  the  air  enters  and  leaves  the  lungs 
freely  without  relieving  the  dyspnoea  or  the  cyanosis.  This  condition 
usually  terminates  fatally,  but  when  the  amount  of  air  sucked  in  is  very 
small,  the  obstruction  may  be  overcome  and  the  circulation  re-established. 
In  these  cases,  it  is  not  uncommon  for  a  small  patch  of  pneumonia  to 
form  where  the  bubbles  of  air  and  blood  have  collected. 

The  accident  is  so  sudden  and  dangerous,  that  the  possibility  of  its 
occurrence  should  always  be  borne  in  mind  by  surgeons,  especially  when 
operating  about  the  neck,  and  if  veins  must  be  divided,  they  should  be 


OPERATIONS  AND  THEIR  MANAGEMENT  123 

clamped  before  division  if  possible  ;  if,  however,  this  cannot  be  done, 
the  proximal  end  should  be  compressed  at  once  by  the  finger,  so  as  to 
prevent  the  accidental  entrance  of  air  ;  a  clamp  is  then  put  on  as  quickly 
as  possible  and  the  operation  is  not  proceeded  with  until  the  divided 
ends  of  the  vein  have  been  closed.  The  accident  is  most  likely  to 
happen  when  a  vein  has  been  only  partially  divided,  and  when  the  rent 
in  its  wall  is  made  during  the  surgeon's  manipulations,  as  for  instance  in 
pulling  forward  the  thyroid  gland  during  thyroidectomy.  A  charac- 
teristic hissing  sound  is  heard  as  the  air  enters  the  vein,  and  an  operator 
who  is  on  the  look-out  for  this  complication  may  thus  detect  it  before 
there  is  time  for  the  general  symptoms  to  develop. 

TREATMENT. — If  symptoms  pointing  to  entry  of  air  into  a  vein 
arise  during  the  course  of  an  operation,  digital  pressure  should  be  made 
over  the  divided  vein  immediately,  and  the  wound  flooded  with  saline 
solution  so  as  to  prevent  further  entry  of  air.  The  next  point  is  to  try  to 
force  the  air  out  from  the  vessels  in  the  chest  by  forcibly  compressing  the 
chest,  while  at  the  same  time  the  pressure  on  the  vein  is  relaxed  so  as 
to  allow  the  air  and  frothy  blood  to  be  poured  out  through  its  open  end  ; 
the  vein  is  again  compressed  when  the  chest  is  allowed  to  expand,  and 
so  on.  The  removal  of  the  frothy  blood  may  also  be  attempted  by 
aspirating  the  vein  ;  a  small  tube,  such  as  a  sterilised  catheter,  is  intro- 
duced into  it,  the  end  of  the  vein  compressed  tightly  around  it,  and  then 
an  attempt  made  to  suck  the  froth  out.  As  a  rule,  however,  death  is 
immediate  when  a  large  quantity  of  air  has  passed  in. 

SYNCOPE. 

Syncope  is  not  an  infrequent  complication  of  operations  ;  by  the  term 
is  meant  complete  arrest  of  the  heart's  action,  accompanied  by  loss  of 
consciousness.  In  shock,  on  the  other  hand,  the  loss  of  consciousness  is 
not  complete  and  the  pulse  is  always  to  be  felt,  although  it  is  often  very 
feeble.  Syncope  or  faintness  may  result  from  sudden  loss  of  blood  ; 
from  withdrawal  of  blood  to  another  part,  as  in  tapping  the  abdomen  for 
ascites  ;  or  reflexly  from  sudden  nervous  shock,  especially  if  the  patient 
be  not  fully  anaesthetised.  When  the  patient  is  not  under  an  anaesthetic, 
syncope  is  usually  preceded  by  vertigo,  tinnitus,  nausea,  and  imperfect 
sight,  and  these  symptoms  are  followed  by  arrest  of  the  heart's  action, 
cessation  of  bleeding,  marked  pallor,  dilated  pupils,  a  cold  sweat  over  the 
forehead,  cold  extremities,  feeble  or  absent  respiration,  and  total  loss  of 
consciousness.  The  condition  is  due  to  deficient  supply  of  blood  to  the 
brain.  Except  in  extreme  cases,  the  arrest  of  the  heart's  action  is  only 
momentary,  and  recovery  is  indicated  by  sighing  and  gasping  respirations, 
reappearance  of  the  pulse,  and  gradual  return  of  consciousness. 

In  the  treatment  of  syncope  it  must  be  borne  in  mind  that  the 
symptoms  are  essentially  due  to  absence  of  blood  from  the  brain,  and 


124 


WOUNDS 


steps  should  be  taken  to  remedy  this.  Before  syncope  is  fully  established 
it  is  often  sufficient  to  depress  the  patient's  head  well  between  his  knees, 
so  that  it  is  at  a  considerably  lower  level  than  the  heart,  when  the  face 
will  flush  and  the  feeling  of  faintness  will  pass  off.  When  syncope  is 
established,  it  should  be  an  invariable  rule  to  lower  the  patient's  head 
at  once ;  there  is  nothing  more  dangerous  than  to  leave  him  sitting  up, 
or  with  his  head  reclining  upon  a  pillow  ;  the  heart  may  not  act  again  in 
time  to  supply  blood  to  the  vital  centres  while  recovery  can  still  take 
place.  It  is  well  also  to  elevate  the  legs  so  that  any  blood  present  in  the 
lower  extremities  may  run  back  into  the  larger  vessels.  The  chest 
also  must  be  free,  and  there  must  be  nothing  tight  around  the  neck. 
Sudden  shocks  to  the  external  surface  will  set  up  the  heart's  action  again, 
the  favourite  plan  being  to  bare  the  chest  and  dash  cold  water  over  it, 
or  slap  it  with  wet  towels.  Cold  water  dashed  over  the  head,  or  brandy 
rubbed  on  the  lips  and  gums,  has  similarly  a  good  effect.  There  must 
be  plenty  of  fresh  air  ;  no  crowd  should  be  allowed  to  gather  around  the 
patient,  and  when  he  is  able  to  swallow,  a  little  brandy-and-water,  or 
other  stimulant,  will  aid  recovery. 

When  syncope  occurs  during  the  course  of  an  operation,  the  patient 
should  be  pulled  up  to  the  end  of  the  table  and  his  head  allowed  to  hang 
over  it,  or  the  foot  of  the  table  may  be  tilted  up.  Artificial  respiration 
may  be  required,  and  slapping  the  chest  with  wet  towels  ;  the  application 
of  the  Faradic  current  to  the  region  of  the  phrenic  nerves  may  be  of 
considerable  help.  This  is  best  done  by  means  of  two  moist  electrodes 
about  the  size  of  a  shilling,  connected  with  an  induction  coil,  which  are 
pushed  forwards  beneath  the  posterior  edge  of  the  stern o-mastoid  just 
above  the  clavicle  on  each  side,  and  a  current  of  five  to  fifteen  milli- 
amperes  then  made  and  broken  from  fifteen  to  thirty  times  per  minute. 
Each  closure  of  the  current  causes  an  inspiration,  followed  by  an 
expiratory  effort.  There  is,  however,  a  risk  of  stimulating  the  vagi  and 
still  further  embarrassing  the  heart.  Direct  stimulation  to  the  region 
of  the  heart  seems  to  do  no  good  and  may  be  actually  harmful. 

AFTER-TREATMENT  OF  OPERATIONS. 

After  the  operation  is  completed,  the  patient  should  be  put  to  bed  as 
quickly  and  gently  as  possible,  and  wrapped  up  in  warm  blankets.  In 
most  cases  he  should  lie  on  his  back  with  only  a  thin  bolster  under  the 
head.  The  room  should  be  rapidly  cleared  and  darkened,  and  the  patient 
left  perfectly  quiet.  If  this  be  done,  the  narcosis  may  pass  into  ordinary 
sleep,  which  may  last  an  hour  or  two,  and  the  patient  may  have  no  pain 
at  all  when  he  wakes  up ;  at  any  rate,  the  worst  of  the  pain  will  have 
passed  off,  and  the  sickness  will  not  be  so  great.  If  the  patient  be  at  all 
collapsed  an  enema  of  hot  saline  solution  (100°  F.)  should  be  given  as 
soon  as  he  is  back  in  bed.  At  least  a  pint  should  be  given. 


OPERATIONS   AND  THEIR  MANAGEMENT  125 

The  recumbent  position  is  required,  in  most  cases  at  any  rate,  until 
the  sickness  has  passed  off,  but  the  rigidity  with  which  this  is  enforced 
is  becoming  relaxed,  and  many  patients  are  now  allowed  to  assume  a 
more  upright  position  almost  immediately  after  an  operation.  While 
sitting  a  patient  up  in  bed,  the  pulse  must  be  carefully  watched,  and 
the  patient  laid  flat  on  his  back  if  it  show  any  sign  of  failing.  The 
surgeon  must  use  his  judgment  as  to  the  immediate  administration  of 
morphine  or  heroin. 

The  patient  should  always  be  seen  on  the  evening  of  the  operation  in 
case  he  be  in  pain,  for  which  morphine  may  be  necessary ;  in  case  any 
bandage  be  too  tight  and  require  cutting  ;  also  in  case  there  be  retention 
of  urine,  which  may  occur  not  only  after  rectal  and  perineal  operations, 
but  sometimes  in  other  cases.  Other  troubles  of  which  the  patient  may 
complain  are  the  occurrence  of  colicky  pains  and  pain  in  the  loins.  Colicky 
pains  are  common  after  abdominal  operations,  and  seldom  subside 
entirely  until  the  bowels  have  acted ;  they  can  be  diminished  by 
enemata  and  the  passage  of  a  long  rectal  tube.  Pain  in  the  back  is  a 
very  common  complaint  with  people  who  have  been  in  vigorous  health 
before  the  operation,  especially  when  the  operation  has  been  prolonged 
and  the  patient  has  to  lie  on  his  back  afterwards.  This  passes  off 
in  twenty-four  or  thirty-six  hours,  but  while  it  lasts  it  causes  consider- 
able discomfort.  Aspirin  in  doses  of  fif teen  grains  generally  relieves  this ; 
if  necessary,  it  may  be  given  in  a  saline  enema.  A  pillow  or  an  india- 
rubber  hot-water  bottle  under  the  back  also  relieves  it  to  some  extent, 
and  when  we  expect  that  it  may  happen — e.g.  in  prolonged  operations 
— it  is  well  to  place  a  pillow  under  the  loins  when  the  patient  is  put 
upon  the  operating  table. 

Feeding. — Neither  food  nor  drink  should  be  given  for  three  or  four 
hours  after  the  operation  ;  at  most,  a  small  quantity  of  very  hot  water 
or  a  teaspoonful  of  brandy-and-water  if  absolutely  necessary.  At  the  end 
of  that  time  beef-tea  may  be  given  if  the  patient  desire  food,  and  this  may 
be  alternated  with  milk-and-soda  after  about  six  hours,  if  there  be  no 
sickness.  A  cup  of  hot  weak  tea  is  often  the  first  thing  that  the  patient 
relishes. 

It  is  well  not  to  push  the  feeding  for  the  first  twenty-four  hours, 
unless  the  patient  be  very  weakly,  and  even  then  two  or  three  nutrient 
enemata  or  zyminised  suppositories  administered  at  intervals  of  four 
hours  are  better  than  feeding  by  the  mouth.  If  feeding  by  the  mouth  be 
commenced  too  soon,  or  pushed  too  energetically,  it  is  apt  to  bring  on 
serious  sickness.  For  the  treatment  of  vomiting  after  an  anaesthetic, 
see  p.  478.  In  babies  still  at  the  breast,  feeding  can  be  discontinued  until 
the  child  seems  anxious  for  food.  No  attempt  should  be  made  to  force 
the  child  to  take  the  breast,  but  if  he  seems  to  want  to  do  so,  it  may  be 
permitted  without  risk.  Very  young  children  are  much  less  sick,  and  are 
generally  in  less  discomfort  after  operations  than  adults. 


126  WOUNDS 

In  cases  where  asepsis  is  obtained,  the  patient  is  free  from  pain  by  the 
next  day  at  latest,  and  rapidly  regains  his  normal  strength  and  requires 
little  further  attention.  If  the  operation  has  been  a  severe  one,  it  may 
be  well  to  keep  him  on  slops — e.g.  beef-tea,  chicken-broth,  milk,  a  little 
champagne  or  other  stimulant — for  forty-eight  hours  after  the  opera- 
tion, and  to  commence  solid  food  on  the  third  day;  he  may  have 
his  ordinary  diet  a  day  or  two  later.  When  the  operation  has  not  been 
severe,  and  there  has  been  no  sickness,  no  restriction  need  be  placed  on 
the  diet  after  the  first  twenty-four  hours. 

Pain. — If  the  patient  be  in  severe  pain  or  be  very  restless,  morphine 
may  be  required.  But  it  must  be  remembered  that  this  drug  is  not  with- 
out serious  disadvantages  ;  its  use  is  often  followed  by  flatulence  and 
constipation,  and  may  be  accompanied  by  much  headache,  nausea,  and 
depression,  thereby  distinctly  increasing  the  patient's  subsequent  dis- 
comfort. If  the  patient  can  tolerate  the  pain,  his  condition  next  day 
will  probably  be  better  than  if  morphine  had  been  administered.  If 
required,  the  drug  should  be  given  in  doses  of  an  eighth  to  a  quarter 
of  a  grain.  Heroin  (gr.  y1^-)  or  aspirin  (gr.  15)  is  often  useful  also 
for  post-operative  pain.  The  latter  drug  is  specially  useful  for 
backache  after  operations. 

Aperients. — The  patient  is  seldom  quite  comfortable  until  the  bowels 
have  been  cleared  out,  and  this  should  be  effected  on  the  second  or  third 
day  after  the  operation.  The  best  plan  is  to  administer  a  dose  of  castor 
oil  in  the  evening,  followed  by  a  Seidlitz  powder  or  an  enema  in  the 
morning.  This  does  not  apply  to  such  operations  as  those  upon  the 
rectum,  etc.,  where  it  is  often  essential  to  keep  the  bowels  confined  for  some 
days.  If  there  be  severe  flatulence,  great  relief  can  often  be  obtained  by  a 
turpentine  enema.  This  may  be  prepared  in  one  of  two  ways  :  In  the 
first,  an  ounce  of  turpentine  is  beaten  into  an  emulsion  with  about  four 
to  six  ounces  of  thin  gruel,  the  yolk  of  an  egg  being  added  to  aid  in  the 
emulsification  ;  this  is  injected  into  the  bowel  first,  and  is  followed  by  a 
large  simple  soap-and-water  enema.  In  the  second,  the  turpentine  is 
simply  stirred  into  the  soap-and-water  and  the  whole  injected  together. 
For  minor  degrees  of  flatulence  the  flatus-tube  is  often  found  to  be  of 
service.  This  is  a  stout  india-rubber  tube  about  twelve  inches  long, 
with  a  terminal  opening  ;  it  is  passed  into  the  bowel  as  far  as  possible, 
and  may  be  with  advantage  left  in  situ.  Change  of  position,  sitting 
the  patient  up  or  turning  him  on  his  side,  often  helps  in  getting  rid  of 
flatus. 

There  are  certain  points  special  to  individual  groups  of  cases,  such 
as  the  length  of  time  the  patient  must  be  confined  to  bed,  etc.,  which 
cannot  be  dealt  with  here,  and  will  be  found  in  connection  with  the 
after-treatment  of  the  individual  operations  concerned. 


CHAPTER  VI. 
MODES   OF  HEALING  OF  WOUNDS. 

BEFORE  discussing  the  treatment  of  wounds,  it  may  be  well  to  refer  to 
the  modes  in  which  they  heal.  There  are  five  methods  by  which  healing 
may  take  place — namely,  by  first  intention,  by  blood-clot,  under 
a  scab,  by  granulation,  and  by  union  of  granulations.  The  particular 
form  of  healing  which  occurs  depends,  in  the  first  place,  on  whether  the 
edges  of  the  wound  have  been  brought  together  or  remain  apart ;  and,  in 
the  second  place,  on  whether  causes  of  suppuration  gain  access  to  the 
wound,  either  at  the  time  of  its  infliction  or  subsequently. 

The  immediate  result  of  the  infliction  of  a  wound  is  bleeding,  and  blood- 
clot  forms  on  the  cut  surface.  When  this  clot  is  wiped  off,  it  is  found 
that  exudation  of  lymph  is  taking  place  beneath  ;  in  other  words,  a  thin 
microscopic  layer  of  inflammation,  going  as  far  as  the  end  of  the  first 
stage — namely,  exudation — has  been  set  up  as  the  result  of  the  irritation 
of  the  knife  and  the  contact  of  foreign  bodies.  The  result  in  all  wounds, 
whatever  their  nature,  whether  the  edges  have  been  brought  together  or 
not,  is  that  lymph  (i.e.  fibrin  entangling  white  corpuscles)  is  poured 
out  and  glazes  the  surface. 

HEALING    BY   '  FIRST  INTENTION.' 

When  no  further  causes  of  inflammation  come  into  play,  notably 
when  no  bacteria  are  present  between  the  cut  surfaces,  this  lymph 
remains  and  glues  the  edges  of  the  wound  together  if  they  have  been 
brought  into  apposition.  It  then  soon  becomes  infiltrated  with  cells ; 
at  first  leucocytes,  and,  later  on,  other  cells  from  the  surrounding  tissues 
pass  into  it.  These  apparently  feed  on  the  remains  of  the  white  corpuscles 
and  destroy  them,  and  they  themselves  enlarge,  become  spindle-shaped, 
and  form  young  fibrous  tissue.  The  result  is  that,  while  after  the  first 
twenty-four  hours  the  two  cut  surfaces  are  separated  by  a  layer  of  young 
cells,  in  the  course  of  three  or  four  days  the  cells  have  become  spindle- 
shaped,  and  some  of  them  are  already  forming  young  fibrous  tissue.  New 

127 


128  WOUNDS 

blood-vessels  are  also  developed  very  much  in  the  same  manner  as  in  the 
embryo.  As  time  goes  on,  the  fibrous  tissue  between  the  two  cut  surfaces 
becomes  more  perfect  and  contracts,  thus  shortening  the  incision  and 
temporarily  depressing  its  surface ;  the  newly  formed  vessels  also  tend  to 
disappear.  Later  on,  this  new  fibrous  tissue  becomes  converted  into  areolar 
tissue ;  when  it  is  situated  in  the  middle  of  fat,  fat-cells  form  in  it,  and 
the  scar  therefore  becomes  looser. 

About  the  second  or  third  day,  the  epithelial  cells  on  the  surface 
begin  to  spread  over  this  narrow  line  of  young  cellular  tissue,  so 
that  there  is  generally  a  continuous  layer  of  epithelium  from  one  edge  of 
the  wound  to  the  other  at  the  end  of  the  fourth  or  fifth  day.  This  process 
is  termed  primary  union,  or  healing  by  first  intention,  and  it  ought  to  be 
aimed  at  in  all  cases,  because  there  is  no  general  disturbance,  no  fever, 
and  no  septic  trouble  in  connection  with  it,  while  the  resulting  scar  is 
small  and,  after  a  time,  almost  unnoticeable. 

Conditions  Inimical  to  Healing  by  First  Intention. — In 
order  to  obtain  healing  by  first  intention  (which  should  always  be  aimed  at 
in  incised  wounds) ,  it  is  essential,  in  the  first  place,  to  bring  the  edges  of 
the  wound  together,  and,  in  the  second  place,  to  avoid  anything  which 
may  lead  to  inflammation.  Among  the  minor  conditions  which  tend  to 
prevent  union  by  first  intention  are,  first,  mechanical  irritation  of  the 
part,  more  especially  in  the  form  of  movement  either  of  the  part  itself 
or  of  the  muscles  beneath  it ;  secondly,  the  presence  of  unduly  tight 
stitches  ;  thirdly,  the  irritation  of  dressings,  or  of  the  chemical  substances 
contained  in  them  or  used  as  lotions.  The  most  common  cause,  however, 
which  leads  to  the  failure  of  union  by  first  intention  or  by  blood-clot, 
and  which  exposes  the  patient  to  the  various  serious  risks  to  be  men- 
tioned later,  is  the  entrance  of  micro-organisms  and  their  growth  either 
in  the  material  on  the  surface  of  the  wound  or  in  the  tissues  themselves. 
The  organisms  which  act  in  this  way  are  essentially  the  pyogenic  organisms, 
and  they  consist  of  various  kinds  of  micrococci,  known  as  the  pyogenic 
cocci,  the  chief  of  them  being  the  staphylococcus  pyogenes  aureus, 
staphylococcus  pyogenes  albus,  and  streptococcus  pyogenes.  These 
organisms  growing  in  a  wound  peptonise  the  materials  on  the  surface,  and 
so  lead  to  the  destruction  of  the  original  tissue,  while  they  produce 
chemical  substances  of  great  potency,  which  act  locally  by  causing,  first, 
granulation,  and  subsequently  suppuration,  and,  generally,  by  setting 
up  febrile  disturbance. 

These  micro-organisms  are  constantly  found  on  the  surface  of  the 
skin  and  mucous  membranes,  more  particularly  in  parts  where  the  skin 
is  moist — as,  for  example,  in  the  perineum,  the  axilla,  between  the  toes, 
and  in  the  dirt  under  the  nails.  They  grow  in  the  old  epithelium  on  the 
surface  of  the  skin  around  the  hairs,  and  they  also  appear  to  penetrate 
into  the  orifices  of  the  sebaceous  and  hair  follicles.  They  vary  in  virulence, 
and  the  different  kinds  vary  also  in  their  mode  of  action.  For  example, 


MODES   OF   HEALING 


129 


the  staphylococci  are  specially  prone  to  cause  the  circumscribed  abscesses, 
whereas  the  streptococci  spread  along  the  lymphatics,  causing  diffuse 
cellulitis,  or  gain  access  to  the  blood-stream  and  set  up  pyaemia. 

HEALING  BY  BLOOD-CLOT. 

When  the  edges  of  the  wound  have  not  been  got  into  accurate 
apposition,  the  space  between  the  cut  surfaces  becomes  filled  with  coagu- 
lated blood,  whilst  the  surfaces  themselves  are  covered  with  lymph.  When 
no  further  causes  of  inflammation  come  into  play,  this  blood-clot  may 
remain  and  form  a  mould  in  which  the  young  cells  develop  and  form 
fibrous  tissue  and  fresh  blood-vessels.  When  nearly  the  entire  blood-clot 
has  become  organised,  epithelial  cells  begin  to  spread  over  this  imperfect 
tissue  from  the  sides.  In  small  wounds  a  thin  layer  of  the  top  of  the 
blood-clot  can  often  be  peeled  off  at  the  end  of  about  fourteen  days, 
leaving  an  epithelium-covered  surface  beneath.  This  process  may  be  termed 
healing  by  blood-clot ;  and,  although  it  is  only  visible  when  the  edges  of 
the  wound  do  not  come  together,  it  occurs  to  some  extent  in  almost  all 
wounds  of  any  depth,  because  the  deeper  parts  of  a  wound  are  seldom 
in  such  accurate  contact  that  only  a  thin  layer  of  lymph  divides  them ; 
when  there  is  any  appreciable  separation,  blood-clot  forms  between  the 
raw  surfaces  and  undergoes  organisation  as  described  above.  Hence, 
even  in  wounds  that  apparently  heal  by  first  intention,  that  process  only 
takes  place  as  a  rule  towards  the  surface,  while  the  deeper  parts  heal  by 
blood-clot. 

HEALING    UNDER  A   SCAB. 

The  process  of  healing  by  scabbing  is  practically  the  same  as  healing 
by  a  thin  layer  of  blood-clot.  The  superficial  layer  of  lymph  and  blood 
dries  up  and  forms  a  scab,  which  protects  the  surface  of  the  wound  from 
irritation,  and  organisation  goes  on  in  the  thin  layer  of  lymph  beneath, 
while  epithelial  cells  spread  in  beneath  the  scab. 

HEALING  BY   GRANULATION. 

When  a  wound  becomes  irritated,  or  when  sepsis  is  present,  healing 
takes  place  by  granulation.  When  this  happens,  the  edges  of  the 
wound  have  either  not  been  brought  together,  or,  if  they  have, 
union  by  first  intention  has  failed,  owing  usually  to  the  occurrence 
of  sepsis.  As  in  both  the  preceding  cases,  effusion  of  lymph  occurs  as  the 
first  change ;  but  the  process  of  inflammation  does  not  stop  there.  Since 
the  causes  of  irritation  continue  to  act,  the  inflammation  goes  on  to  the 
second  stage — namely,  granulation — so  that  all  the  structures  exposed  in 
the  wound  become  covered  with  granulation-tissue.  This  soon  becomes 
arranged  in  the  form  of  little  rosy  buds,  termed  granulations,  which  on 
microscopical  examination  are  seen  to  be  composed  of  actively  growing  cells 
with  numerous  young  blood-vessels.  The  granulations  ultimately  fill 


I3o  WOUNDS 

up  the  wound,  and  epithelium  begins  to  spread  over  their  surface  when 
they  are  nearly  level  with  the  skin.  While  this  process  is  going  on,  the 
cells  of  the  granulation-tissue  in  the  deeper  parts  of  the  wound,  being 
protected  from  irritation  by  the  granulations  on  the  surface,  develop 
into  young  fibrous  tissue,  and  large  numbers  of  the  blood-vessels  become 
obliterated.  This  young  fibrous  tissue  at  once  begins  to  contract,  and 
the  edges  of  the  wound  become  drawn  together,  so  that,  even  before  the 
spread  of  epithelium  has  commenced  at  the  surface,  the  wound  may  be 
much  smaller  than  it  was  when  first  made. 

When  the  young  epithelial  cells  begin  to  spread  over  the  surface 
of  the  sore,  a  delicate  red  line  is  found  around  its  edge,  because  at  first 
the  epithelial  cells  are  young,  transparent,  and  only  in  a  single  layer, 
and  therefore  they  allow  the  red  colour  of  the  granulation-tissue  to  show 
through.  At  a  later  period  the  epithelium  becomes  thicker,  and  a  bluish 
appearance  is  the  result ;  still  later,  when  the  epithelium  has  been  formed 
for  some  time,  the  thick  layer  on  the  surface  becomes  macerated  and 
white,  like  the  skin  of  a  washerwoman's  hand,  and  there  is  a  white  line 
formed.  Thus,  there  are  three  zones  in  a  healing  wound — an  outer  white 
line  shading  off  into  a  blue  one,  and  this  again  shading  off  into  a  delicate 
pink  line.  In  many  cases  this  pink  line  is  not  noticeable  until  the  wound 
has  been  dried,  when  it  will  be  seen  that,  while  the  granulations  on  the 
surface  of  the  unhealed  part  begin  to  ooze  and  become  moist,  the  red 
line  at  the  edge  of  the  wound  remains  dry.  The  detection  of  this  red 
line  is  of  importance,  because  it  implies  that  healing  is  in  active 
progress. 

In  the  final  stages  of  healing  by  granulation  the  new  epithelium 
becomes  thicker  and  thicker  over  the  surface,  so  that  for  some  weeks 
epithelial  scales  are  constantly  forming.  Later  on,  the  wound  contracts, 
and  this  contraction  may  lead  to  very  serious  deformity.  The  structure 
of  the  scar  undergoes  continued  alteration  until  ultimately  it  is  composed 
of  a  mass  of  fibrous  tissue  covered  with  epithelium,  and  containing  very 
few  blood-vessels  ;  there  is  no  development  in  it  of  the  special  structures 
of  the  skin,  such  as  hairs  and  sebaceous  or  sweat  glands. 

During  the  process  of  healing  by  granulation,  the  patient  is  exposed 
to  the  risk  of  severe  local  and  general  troubles  arising  from  the  various 
infective  diseases  due  to  bacteria  which  may  gain  entrance  through  the 
open  wound.  In  any  case,  unless  the  wound  be  aseptic  or  very  small, 
there  is  a  certain  amount  of  fever  ('  traumatic  fever  ' )  during  the  forma- 
tion of  the  granulations,  which  is  due  to  the  absorption  of  poisonous 
products  from  the  decomposition  in  the  wound.  When  granulation  is 
complete — that  is  to  say,  about  the  third  or  fourth  day — the  temperature 
falls  and  the  fever  disappears,  because  the  granulations  do  not  permit 
absorption  of  these  poisonous  products. 

Apart  from  the  danger  of  sepsis,  a  drawback  to  this  mode  of  healing 
is  that  the  scar  is  larger  than  after  healing  by  first  intention,  and  the 


MODES  OF  HEALING  131 

deformity  due  to  the  contraction  of  the  scar  is  sometimes  very  serious ;  it 
is  evident,  therefore,  that  healing  by  granulation  is  not  such  a  desirable 
process  as  is  union  by  first  intention. 

HEALING    BY    UNION   OF    GRANULATIONS. 

In  this  mode  of  healing  the  edges  of  the  wound  are  not  brought 
together  in  the  first  instance,  but  are  intentionally  kept  apart  with 
dressings  until  both  surfaces  are  granulating,  when  the  surfaces  are  washed 
and  brought  together.  The  result  is  that  these  granulating  surfaces 
adhere  over  a  considerable  area  and  union  occurs  rapidly  ;  but  the  risks 
attendant  on  healing  by  granulation,  to  which  reference  has  just  been 
made,  apply  to  this  method  of  healing  also.  It  is  not  a  mode  that  should 
be  deliberately  chosen  when  other  methods  are  available,  but  it  is  well 
to  bear  in  mind  that  healing  may  occur  in  this  way. 


K  i 


CHAPTER    VII. 
THE  TREATMENT  OF  INCISED  WOUNDS. 

THE  great  object  of  wound- treatment  is  to  prevent  the  entrance  of 
organisms  into  the  wound,  or,  when  this  is  impossible — as,  for  example, 
in  operations  about  the  mouth  or  the  rectum — to  hinder  their  growth, 
and  thus  minimise  their  evil  effects.  These  objects  are  effected 
in  two  ways.  The  primary  one  is  to  disinfect  the  skin  of  the  patient 
and  the  hands  of  the  operator  and  his  assistants,  together  with  all  the 
instruments  and  accessories  used  in  the  operation,  so  thoroughly  that 
no  organisms  are  thereby  introduced  into  the  wound.  A  secondary, 
but  very  important,  object  is  to  kill  or  inhibit  the  growth  of  any  organisms 
that  may  accidentally  gain  access  from  any  cause. 

CLASSIFICATION  OF  INCISED  WOUNDS.— There  are 
two  great  classes  of  incised  wounds — viz.  those  made  by  the  surgeon,  and 
those  inflicted  before  the  patient  is  seen  by  him.  Wounds  made  by  the 
surgeon  may  be  again  subdivided  into — (a)  those  made  through  un- 
broken skin  and  not  communicating  with  mucous  surfaces  ;  (b)  those 
made  in  connection  with  previously  existing  sinuses  or  suppurating 
deposits,  or  communicating  with  some  mucous  canal.  The  importance 
of  this  subdivision  is  that,  while  it  is  comparatively  easy  to  exclude 
micro-organisms  from  wounds  of  the  first  class,  it  is  always  difficult  and 
may  be  impossible  to  do  so  in  the  second  variety ;  the  treatment  in  the 
latter  must  therefore  be  directed  towards  minimising  the  ill-effects  pro- 
duced by  the  organisms  after  they  have  gained  entrance. 

TREATMENT  OF   WOUNDS   MADE  BY  THE  SURGEON 
THROUGH   UNBROKEN  SKIN. 

It  is  clear  from  what  has  gone  before  that  the  point  to  be  aimed  at  here 
is  healing  by  first  intention.  If  this  be  obtained,  there  is  rapid  recovery, 
and  a  delicate  scar  is  left,  which  becomes  practically  invisible  later  on, 
while  the  general  septic  affections  or  the  local  inflammatory  troubles 
which  may  occur  if  union  by  first  intention  be  not  obtained  are  avoided. 

132 


TREATMENT  OF  INCISED  WOUNDS  133 

The  conditions  which  favour  healing  by  first  intention  have  already 
been  referred  to  (see  p.  128)  ;  of  these,  the  absolutely  essential  one  is 
asepsis  of  the  wound  ;  in  addition  to  this,  however,  care  has  to  be  taken 
to  bring  the  cut  surfaces  of  the  wound  into  accurate  apposition.  Besides 
this,  causes  of  unrest,  such  as  movement,  irritation  by  the  dressings,  etc., 
must  be  avoided. 

Apposition  of  the  Edges. — The  cut  surfaces  of  the  wound  must  be 
in  accurate  apposition ;  if  not,  an  interval  is  left  which  becomes  filled  with 
blood-clot,  and  although  healing  by  blood-clot  will  occur  if  the  wound 
be  aseptic,  it  is  not  so  good  as  union  by  first  intention.  When  the 
edges  of  the  wound  are  brought  into  apposition,  the  two  should  be  on 
the  same  level.  If  one  be  higher  than  the  other  to  a  very  slight  extent  it 
will  not  matter,  except  in  so  far  that  the  subsequent  cicatrix  will  not  be 
a  fine  delicate  line,  but  will  show  a  definite  ridge.  If,  however,  there  be 


A  B 

FIG.  33. — FAULTY  METHOD  OF  SUTURING  A  WOUND. — In  A  the  suture  Is  in  place  ; 
it  causes  the  skin  on  one  side  to  overlap  that  on  the  other.  In  B  is  seen  the  gap  left 
when  the  suture  is  removed. 


any  marked  difference  in  level  between  the  edges,  and  especially  if  the 
raw  surface  of  the  one  side  be  in  contact  with  the  cutaneous  surface  of 
the  other,  healing  of  the  overlapping  raw  surface  may  not  take  place 
although  the  deeper  parts  will  unite  satisfactorily.  Epithelium  will  not 
spread  over  a  raw  surface  which  is  lying  in  contact  with  epithelium- 
covered  skin ;  and  in  such  a  case  it  is  necessary,  in  order  to  obtain  healing, 
to  pare  away  the  inverted  or  overlapped  edge  of  the  skin,  and  thus  to 
have  two  raw  surfaces  opposed  to  each  other. 

Approximation  of  the  Deeper  Structures. — When  a  wound 
has  to  be  closed,  its  deeper  parts  must  be  approximated  as  well  as  its 
cutaneous  edges.  For  this  purpose  some  surgeons  employ  deep  stitches, 
and  then  put  in  superficial  ones  to  bring  the  skin  together ;  this,  however, 
is  hardly  necessary  in  the  great  majority  of  cases.  By  properly  applied 
pressure  outside  the  wound  (see  p.  151)  it  is  generally  possible  to  bring  the 
deeper  parts  sufficiently  together,  and  then  stitches  need  only  be  employed 
for  the  approximation  of  the  edges  of  the  skin.  In  some  cases,  however, 
deep  stitches  may  be  required  ;  for  example,  when  the  incision  has  been 
carried  through  dense  fibrous  tissue,  as  in  excising  a  portion  of  the  breast, 
a  cavity  may  be  left  which  will  fill  with  blood-clot  unless  the  deeper  parts 


134 


WOUNDS 


FIG.  34. — ANTERIOR  VIEW  OF  THE  BODY  ILLUSTRATING  THE  DIRECTIONS  IN 
WHICH  INCISIONS  SHOULD  BE  MADE. — The  correct  incisions  are  indicated  by  the 
single  dark  lines.  In  them  the  lips  of  the  wound  tend  to  fall  together,  while  those  of 
the  faulty  incisions — denoted  by  ellipses — tend  to  gape.  (This  and  the  following  figure 
are  reproduced  from  Kocher's  Operative  Surgery,  and  English  edition  1903.) 


TREATMENT  OF  INCISED  WOUNDS 


135 


FIG.  35. — POSTERIOR  VIEW  OF  THE  BODY  ILLUSTRATING  THE  SAME  POINT. 


136  WOUNDS 

be  approximated  ;  this  may  interfere  materially  with  healing.  Again, 
when  a  strong  layer  of  fascia,  such  as  the  fascia  lata,  has  been  divided, 
it  is  advisable  to  suture  this  before  the  wound  is  closed.  Sometimes 
deep  sutures  may  be  required  to  relieve  tension  upon  the  skin-edges 
where  a  delicate  scar  is  of  importance  (see  p.  137). 

Sutures. — The  choice  of  the  material  for  stitches  is  determined  by 
the  asepticity  of  the  wound  and  the  amount  of  tension  upon  its  edges. 
As  we  are  now  dealing  only  with  aseptic  wounds,  we  shall  only  consider 
the  question  of  stitches  in  (a)  those  in  which  there  is  no  tension 
on  the  edges;  (b)  those  in  which  the  tension  is  great;  and  (c)  those 
in  which  it  is  only  moderate  in  amount.  It  is  well  to  bear  in  mind,  in 
connection  with  wounds  on  the  face  or  neck,  that  more  unsightliness  is 
produced  by  the  stitch-marks  after  healing  by  first  intention  than  by 
the  cicatrix  itself ;  therefore,  under  these  circumstances,  the  avoidance 
of  stitch-marks  is  a  matter  of  considerable  importance.  Whatever  be 
the  material  used  for  stitches  it  must  be  sterile  ;  this  point  is  fully  dealt 
with  on  p.  93,  where  the  method  of  preparing,  storing,  and  using  each  is 
detailed. 

(a)  When  there  is  no  Tension. — When  there  is  no  tension  on  the 
edges  of  the  wound,  and  when  as  delicate  a  scar  as  possible  is  desired, 
as  in  operations  upon  the  face  and  neck,  the  finest  material  only  should  be 
used,  and  the  stitches  should  not  be  put  closer  together  than  is  absolutely 
necessary  to  keep  the  edges  in  contact ;  they  should  be  inserted  as  close 
to  the  line  of  incision  as  possible.  Under  these  circumstances  fine  horse- 
hair or  silkworm-gut  is  probably  the  best  material  to  employ.  The  size 
of  the  stitch-marks  may  be  reduced  still  further  if  a  fine  sewing-needle 
be  employed.  When,  however,  there  is  no  special  reason  for  avoiding 
stitch-marks,  the  best  and  quickest  plan  is  to  close  the  wound  by  a  con- 
tinuous button-hole  suture  of  fine  silk,  using  the  ordinary  triangular 
straight  needle.  This  suture  is  described  and  illustrated  on  p.  142. 

How  to  obtain  a  very  fine  Scar. — This  is  a  point  of  importance  in 
operations  on  the  face  and  neck. 

The  first  essential  point  is  the  direction  of  the  incision.  The  skin  is 
not  a  homogeneous  structure,  but  has  distinct  lines  of  cleavage  which 
run  roughly  at  right-angles  to  the  long  axis  of  the  body.  Their  exact 
distribution  is  shown  in  Figs.  34  and  35.  Incisions  made  along  these  lines 
produce  much  finer  scars  than  those  made  at  right-angles  to  them. 

The  second  point  is  to  avoid  tension  on  the  skin.  To  accomplish  this 
in  some  cases  it  is  necessary  to  insert  deep  buried  sutures  so  as  to  bring 
the  deeper  parts  of  the  wound  together.  This  is  specially  important 
when  it  has  been  necessary  to  remove  portions  of  the  skin.  In  operations 
on  the  neck  it  is  well  to  suture  the  platysma  and  deep  fascia  with  fine 
catgut. 

The  third  point  is  the  method  of  inserting  the  sutures.  Several 
methods  may  be  adopted. 


TREATMENT  OF  INCISED  WOUNDS 


137 


Buried  Sutures. — An  excellent  way  of  introducing  a  buried  suture 
is  to  take  a  curved  Hagedorn  needle,  threaded  with  the  finest  catgut,  and 
pass  it  through  the  fat  and  deeper  part  of  the  dermis  on  one  side  of  the 
wound,  and  then  through  the  fat  and  deeper  part  of  the  dermis  on  the 
other,  the  needle  being  made  to  enter  the  fat  and  emerge  through  the 
dermis  on  the  one  side,  and  vice  versa  on  the  other.  Several  stitches 


FIG.  36. — A  BURIED  SUTURE.  The  figure  shows  how,  by  making  the  free  end  of  the 
suture  emerge  on  each  side  through  the  deeper  part  of  the  dermis  and  the  adjacent 
subcutaneous  tissues,  the  knot  can  be  pushed  out  of  the  way  among  the  fat  when  it  is  tied. 
If  it  were  done  in  the  reverse  way  the  knot  would  lie  between  the  lips  of  the  incision, 
and  would  interfere  with  coaptation.  The  ends  of  the  suture  are  cut  short  and  pushed 
down  out  of  the  way  with  a  probe. 

are  passed,  and  they  are  then  tied  and  the  ends  cut  short,  the  knot  being 
pushed  down  into  the  fatty  tissues  beneath  the  dermis  (see  Fig.  36). 
These  sutures  hold  the  deeper  parts  of  the  skin  firmly  together.  A  strip 
of  gauze  is  then  fixed  upon  one  side  of  .the  wound  with  collodion,  and 
when  this  is  dry,  the  skin  on  the  other  side  is  pressed  inwards  towards 
the  line  of  incision  and  the  free  end  of  the  gauze  strip  is  fastened  down 


FIG.  37. — HALSTED'S  INTRA-DERMIC  SUTURE. — The  suture,  which  is  commenced 
at  one  end  of  the  incision,  is  grasped  in  a  pair  of  pressure  forceps,  passed  across  and 
across  the  wound  in  the  substance  of  the  dermis  and  finally  brought  out  at  the 
opposite  end  of  the  incision.  The  wound  is  closed  by  making  traction  on  the  ends  of 
the  suture. 

upon  it  with  collodion.  As  far  as  the  gauze  and  collodion  are  concerned, 
the  procedure  closely  resembles  the  old-fashioned  method  of  applying 
strapping  to  draw  the  edges  of  wounds  together,  and  is  similar  to  the 
plan  that  is  often  adopted  in  hare-lip  operations.  The  epithelial  edges 
are  thus  approximated,  and  stitch-marks  are  absolutely  avoided,  so  that 
only  a  very  delicate  linear  scar  is  left,  which  in  a  short  time  becomes 
unnoticeable. 


WOUNDS 


Halsted's   Intra-dermic   Suture. — Halsted    has   modified    the    buried 

suture  by  inserting  a  single  silkworm-gut    or    catgut   suture  in  the 

manner  shown   in   Fig.  37. 

This  method  is,  however, 
only  suitable  for  short  and 
straight  incisions  and  requires 
a  good  deal  of  practice  to  per- 
form quickly  and  efficiently. 
A  special  long,  slightly  flexible 
needle  is  of  advantage. 

Michel's  Metal  Clips.  — 
These  are  small  pieces  of  malle- 
able white  metal  bearing  a 
small  spike  at  each  end.  Before 
insertion  of  the  suture  these 
spikes  project  at  right-angles 
to  the  long  axis  of  the  clip, 
but  when  the  latter  is  bent 
into  a  semicircle  they  point 
inwards  towards  one  another. 
The  edges  of  the  wound  are 
held  in  apposition  with  two 
pairs  of  fine  toothed  forceps  so 
as  to  produce  a  slight  ridge 
with  the  incision  at  the  top  of 
it;  the  clip  is  then  held  in  a 
special  pair  of  dissecting-for- 
ceps  (each  blade  being  grooved 
to  receive  the  ends  of  the  clip) 
over  the  ridge,  and  the  clip  is 
bent  by  gentle  pressure  on  the 

forceps  so  as  to  force  the  spikes  lightly  into  the  skin.      If  too  great 

pressure  be  exerted  in  applying  these  clips  there  will  be  sloughing  of 

the  skin   between  their  ends. 

The  clips  are  inserted  about 

half-an-inch   apart    along   the 

whole  length  of  the  incision. 

The  clips  should  be  removed 

about  the  fifth  day,  preferably 

With    the     Special     instruments          FlG-  39-— REMOVAL  OF  MICHEL'S  CLIPS  BV  FORCEPS.— 
,  j    ,  ,  ...  Ordinary  Spencer  Wells's  forceps  can  be  used,  but  special 

SOld   tor  the  purpose  ;    if    these       forceps,  shown  in  the  figure,  are  made  for  the  purpose. 

be   not    available,   one    blade 

of  a  Spencer  Wells's  forceps  may  be  passed  into  the  concavity  of  the 
clip  and  the  blades  closed ;  this  flattens  out  the  clip  and  so  liberates 
its  points. 


FIG.  38. — MICHEL'S  CLIPS. — The  sketch  shows  both  the 
method  of  applying  the  clips  by  pinching  them  up  with 
special  forceps,  and  that  of  removing  them  by  inserting 
the  special  hooks  and  straightening  them. 


TREATMENT  OF   INCISED  WOUNDS 


139 


FIG.  40.  —  LISTER'S 
NEEDLE  FOR  THE  IN- 
TRODUCTION OF  SILVER 
WIRE. 


If  properly  applied,  these  clips  leave  little  to  be  desired,  but  if  they 
happen  to  slip,  a  very  inaccurate  and  unsightly  scar  may  result ;  more- 
over, even  after  considerable  practice,  it  is  impos- 
sible to  gauge  the  pressure  they  exert  so  accurately 
as  to  be  sure  that  no  sloughing  will  ensue — a  most 
important  matter  in  wounds  upon  the  face  and 
neck.  They  are  rather  more  painful  than  ordinary 
sutures. 

If  all  tension  can  be  removed  by  deep  sutures, 
admirable  scars  may  be  obtained  by  the  use  of  fine 
continuous  horsehair  sutures  inserted  with  a  fine 
round  sewing-needle  at  the  very  margin  of  the  inci- 
sion. The  round  needle-point  pushes  aside  the  fibres 
of  the  skin  and  does  not  divide  them  as  triangular 
needles  or  those  with  cutting  edges  do.  The  sutures 
should  be  removed  on  the  fourth  day  and  a  piece  of 
gauze  fixed  on  with  collodion  as  described  above 
(see  p.  137). 

(b)  When  there  is  Great  Tension.— After  operations 
for  the  removal  of  tumours — as,  for  example,  car- 
cinoma of  the  breast — there  is  often  a  great  defi- 
ciency of  skin,  and  the  edges  of  the  wound  will 
not  come  together  without  considerable  traction. 
If  the  skin  be  pinched  up  by  an  unduly  tight  stitch,  persistent  irritation 
is  caused,  and  union  may  fail ;  at  any  rate  it  will  not  be  so  rapid  and  firm 

as  it  should  be.  When  inserting  sutures, 
therefore,  it  is  important  to  see  that  no 
stitch  is  tighter  than  is  necessary  to  approxi- 
mate the  edges  of  the  skin.  When  there  is 
much  difficulty  in  bringing  the  edges  to- 
gether, however,  some  irritation  must  neces- 
sarily be  caused  by  the  stitches ;  but  this  can 
be  largely  reduced  by  introducing  a  few  so- 
called  '  stitches  of  relaxation '  (Lister)  at 
some  considerable  distance  from  the  edges 
of  the  wound.  The  tension  upon  these  may 
be  great,  and  they  may  subsequently  cut 
through  the  soft  parts  to  a  certain  extent ; 
but  they  serve,  temporarily  at  any  rate,  to 
relax  the  tension  upon  the  edges  of  the 
wound,  which  may  then  be  stitched  to- 
gether without  any  tension,  with  the  result 
that  they  will  heal  by  primary  union. 
Hence,  two  classes  of  sutures  are  used 
when  the  edges  of  the  wound  require  to  be  pulled  together — namely, 


FIG.  41. — METHOD  OF  THREADING 
LISTER'S  NEEDLE  WITH  SILVER 
WIRE. 


i4o  WOUNDS 

'  stitches  of  relaxation,'  and  others  which  may  be  termed  '  stitches  of 
coaptation.' 

'  Stitches  of  Relaxation.' — Stitches  of  relaxation  require  to  be  inserted 
at  a  considerable  distance  from  the  edges  of  the  wound,  and  must  be 
reasonably  stout,  because  a  fine  stitch  would  cut  its  way  out  too  quickly  ; 
the  best  material  for  this  purpose  is  thick  silver  wire  (Nos.  I  or  2  gauge), 
threaded  into  special  needles,  '  Lister's  pattern  '  (see  Fig.  40).  The  wire 
is  threaded  through  an  eye  which  is  at  some  distance  from  the  end, 
while  between  the  eye  and  the  end  of  the  needle  there  is  a  groove,  into 
which  the  wire  is  pressed,  so  that  where  the  needle  goes  the  wire  follows 
without  any  unnecessary  tearing  of  the  structures  through  which  it 
passes.  In  threading  these  needles,  two  or  three  inches  of  the  wire  are 
passed  through  the  eye  and  flattened  carefully  into  the  groove  on  each 
side  ;  the  needle  is  then  held  with  forceps,  and  the  two  ends  of  the  wire 
are  carefully  twisted  together  (see  Fig.  41).  If  one  end  of  the  wire  be 
merely  twisted  round  the  other,  a  number  of  projections  are  left,  which 
catch  in  the  wound  when  the  stitch  is  pulled  through.  Pure  drawn 
silver  wire  without  any  alloy  must  be  employed ;  its  properties  and  the 
method  of  sterilising  and  preparing  it  for  use  are  described  fully  on  p.  95. 

If  the  tension  be  not  very  great,  the  wire  is  tied  into  the  first  half 
of  a  reef-knot,  the  ends  are  turned  up  at  right-angles  and  then  clipped 
off  flush  with  the  surface  of  the  wire  (see  Fig.  42) ;  if  the  wire  be  stout,  it 
will  hold  perfectly  well,  while  there  is  no  projecting  end  left  to  catch  in 
the  dressing.  When  the  tension  is  great,  a  second  twist  must  be  made 
and  the  ends  cut  off  and  bent  down  on  to  the  skin.  The  ends  of  the 
wire  may  be  prevented  from  catching  in  the  dressing  by  interposing  a 
layer  of  oiled  silk  protective  between  them  and  the  wound.  Enough 
of  these  deep  silver-wire  stitches  must  be  put  in  to  enable  the  edges  of 
the  wound  to  be  brought  together  without  any  tension. 

Undermining  Flaps. — When  much  skin  has  been  taken  away,  it  is 
often  impossible  to  suture  the  edges  accurately  unless  the  skin  be  freed 
by  undermining  it  widely.  By  this  means  the  skin  and  fat  are  separated 
from  the  deeper  parts  for  a  considerable  distance,  and  the  elasticity  of 
the  skin  allows  the  flap  thus  formed  to  stretch,  and  the  cut  edges  to  meet. 
Full  details  of  the  method  will  be  found  on  p.  157. 

Button  Sutures. — When  the  tension  is  very  great,  the  '  button  sutures  ' 
introduced  by  Lord  Lister  may  be  employed  with  advantage.  A  needle 
threaded  with  stout  silver  wire,  as  described  above,  is  inserted  through  the 
skin  several  inches  from  the  edge  of  the  undermined  flap,  at  the  outer 
limit  of  the  undermining,  and  the  free  end  of  this  is  attached  to  a  lead 
button  (see  Fig.  42).  The  wire  is  then  carried  across  the  wound,  and 
the  needle  brought  out  through  the  skin  at  the  corresponding  spot  on  the 
opposite  side  where  the  undermining  ceases.  The  needle  is  then  cut  off, 
and  over  the  cut  end  of  the  wire  is  threaded  a  second  button,  which  is 
pushed  as  far  down  as  possible,  while  firm  traction  is  made  on  the  wire, 


TREATMENT  OF   INCISED   WOUNDS 


141 


and  the  button  is  then  secured  in  place.  Only  a  few  of.  these  button 
stitches  need  be  inserted ;  as  a  rule,  two  pairs  suffice  in  a  breast  case. 
The  larger  the  button  used  the  better  ;  the  pressure  is  then  more  evenly 
distributed  over  the  skin,  and  there  is  less  likelihood  of  sloughing  from 
its  pressure.  In  order  to  avoid  this,  it  is  well  to  adopt  the  precaution  of 
inserting  a  small  wad  of  gauze  between  each  button  and  the  skin  ;  a  small 
slough  generally  forms  where  the  wire  penetrates  the  skin,  but  this  causes 


FIG.  42. — METHOD  OF  SUTURING  A  WOUND  WHERE  THERE  is  MUCH  TENSION  on 
THE  EDGES.  On  either  side  is  a  pair  of  button  sutures,  showing  the  figure-of-eight 
arrangement  by  which  the  wire  is  fastened.  In  the  centre  is  a  relaxation  stitch  of  stout 
silver  wire  showing  the  manner  in  which  the  wire  is  tied  and  its  ends  clipped  off.  A  con- 
tinuous '  button-hole  '  stitch  unites  the  edges  of  the  skin  which,  by  the  aid  of  the 
button  sutures  and  the  silver  wire  stitch,  come  together  without  tension.  The  pucker- 
ing of  the  skin  caused  by  the  tension  upon  the  button  sutures  and  silver  wire  stitch  is 
also  indicated.  The  skin  has  been  freely  undermined. 

no  trouble  in  an  aseptic  wound,  and  heals  readily  when  the  buttons  are 
removed.  Several  '  stitches  of  relaxation '  inserted  midway  between 
the  buttons  and  the  edge  of  the  wound  (see  p.  140)  will  also  be  required 
to  take  off  tension  from  the  edges  of  the  wound. 

The  button  stitches  are  usually  left  in  for  about  five  or  six  days ; 
they  are  the  first  sutures  to  be  removed,  partly  because  the  skin  will  not 
retract  after  being  stretched  for  that  length  of  time,  and  partly  because 
they  are  apt  to  cause  a  slough  if  they  are  in  longer. 

(c)  When  there  is  Moderate  Tension. — When  only  moderate  trac- 
tion is  required  to  bring  the  edges  together,  a  very  good  material  for  a 
stitch,  and  one  that  is  intermediate  between  one  of  '  relaxation '  and 


142 


WOUNDS 


one  of  '  coaptation,'  is  silkworm  or  fishing  gut.  This  should  be  fairly  thick, 
and,  if  a  good  hold  of  the  skin  be  taken,  the  latter  can  be  made  to  bear 
a  considerable  amount  of  tension  without  bad  results. 

'  Stitches  of  Coaptation.' — It  was  formerly  the  practice  to  use  interrupted 
sutures  to  bring  the  edges  of  the  wound  accurately  together,  each  suture 
being  separately  inserted,  knotted,  and  divided.  Most  surgeons  now 
employ  a  continuous  suture,  which  has  the  advantage  that  the  edges 
are  more  accurately  approximated  by  it  and  that  it  is  much  more  rapidly 
inserted,  a  point  of  importance  when  a  large  wound  requires  to  be  closed 
at  the  end  of  a  long  or  severe  operation. 


FIG.  43. — METHOD  OF  INSERTING  THE  BUTTON-HOLE  SUTURE. — The  sketch  shows 
how  the  needle  is  brought  out  inside  the  loop  formed  by  the  thread  from  the  last 
section  of  the  stitch. 

The  best  form  of  continuous  suture  is  that  known  as  the  blanket  or 
button-hole  stitch  (see  Fig.  43).  The  suture  is  first  inserted  at  one  end 
of  the  wound  and  tied ;  then,  instead  of  cutting  the  thread,  the  needle 
is  passed  through  the  two  edges  of  the  wound,  and  brought  out 
inside  the  loop  formed  by  the  thread,  and  drawn  tight,  and  this  is  con- 
tinued till  the  whole  wound  is  stitched  up ;  the  end  may  be  secured 
either  by  leaving  the  last  loop  long  and  tying  a  knot  between  it  and 
the  free  end  of  the  thread,  or  by  taking  several  turns  of  the  thread 
around  the  needle  as  it  forms  the  last  loop  and  then  tightening  it  up 
(see  Fig.  44).  The  result  is  that  along  one  side  of  the  wound  there  is 
a  continuous  thread  of  silk,  which  acts  very  like  the  old  quilled  suture. 


TREATMENT  OF  INCISED  WOUNDS 


143 


This  stitch  is  better  than  the  running  suture,  which  tends  to  pucker  up 
the  edges,  if  drawn  tight,  and  may  even  cause  gangrene  of  portions  of 
them.  If  the  dressings  have  been  allowed  to  dry,  the  threads  will  be 
found  stuck  together  with  blood  after  a  few  days,  and  if  any  one  of  the 
stitches  be  too  tight,  it  can  be  divided  or  removed  without  the  rest  of  the 
stitch  necessarily  giving  way.  The  best  material  for  the  continuous  suture 
is  silk,  of  the  variety  known  as  Chinese  twist,  varying  in  thickness  accord- 
ing to  the  tension  to  which  it  is  exposed.  When  there  is  no  tension,  quite 
a  fine  silk  is  sufficient ;  but  when  there  is  much,  it  is  better  to  use  silk 


FIG.  44. — METHODS  OF  FINISHING  OFF  THE  BUTTON-HOLE  SUTURE.  A.  As  the  needle 
emerges  through  the  skin  for  the  last  time,  the  thread  is  twisted  around  it  three  or  four 
times.  The  needle  is  then  pulled  through  and  the  stitch  pulled  tight.  A  perfectly 
satisfactory  knot  can  be  thus  made  with  a  little  practice.  B.  Shows  a  method  very  com- 
monly used.  When  the  needle  is  passed  through  the  skin  for  the  last  time  it  is  not 
brought  out  inside  the  loop  from  the  last  stitch  ;  the  free  end  shown  on  the  left-hand  side 
of  the  incision  is  taken  in  one  hand,  the  loop  shown  on  the  right-hand  side  in  the  other, 
and  the  two  are  then  tied  together.  This  is  a  simple  method,  but  causes  a  little 
puckering.  C.  Shows  a  useful  method  that  may  be  employed  to  obviate  this  puckering. 
In  passing  the  needle  through  the  skin  for  the  last  time  it  is  made  to  go  in  the  opposite 
direction,  i.e.  in  the  diagram  from  left  to  right,  whereas  the  rest  of  the  stitch  is  made 
from  right  to  left.  The  free  end  shown  on  the  left-hand  side  of  the  incision  is  then 
held  in  one  hand  while  traction  is  made  upon  the  needle  with  the  other  ;  the  result  is 
that  the  last  loop  is  drawn  tight  and  the  wound  is  closed.  The  free  end  on  the  one 
side  and  the  loop — or  the  two  free  ends  if  the  needle  be  cut  off — on  the  other  are  then 
tied  together.  This  is  a  very  simple  and  effective  plan. 

of  medium  thickness,  as  the  fine  thread  cuts  out  very  quickly  under  these 
circumstances.  This  suture  can  also  be  made  with  horsehair  or  silkworm- 
gut  ;  the  strands  of  the  latter  are,  however,  only  about  fourteen  inches 
long,  and  several  must  be  used  for  a  long  incision.  They  are  non- 
absorbent,  and  are  therefore  very  useful  in  septic  wounds. 

Removal  of  Sutures. — Button  sutures  should  be  removed  in  about 
five  or  six  days.  When  there  are  also  silver  '  relaxation  stitches,'  and 
the  wound  is  dressed  for  the  purpose  of  removing  the  buttons,  the  con- 
tinuous silk  suture  uniting  the  edges  of  the  wound  can  as  a  rule  be  taken 
out  at  the  same  time,  only  the  deep  silver  stitches  being  left.  The  period 
at  which  these  latter  should  be  removed  must  depend  on  the  firmness  of 
union  between  the  edges  ;  generally  they  can  all  be  taken  out  at  the  end 


144 


WOUNDS 


of  a  week  or  ten  days.  If  there  be  any  point  where  the  strength  of  the 
union  is  doubtful — as  for  instance  where  a  triangular  flap  of  skin  has  been 
dragged  up  to  meet  two  other  flaps — the  stitches  at  the  apex  of  the  flap 
should  be  left  in  place  for  a  fortnight.  Unless  button  sutures  have  been 
used,  there  is  no  necessity  to  dress  the  wound  for  the  purpose  of  removing 


FIG.  45. — SUTURE  OF  AN  ABDOMINAL  WOUND  IN  FOUR  LAYERS. — First  layer. 
The  peritoneum  and  the  posterior  layer  of  the  sheath  of  the  rectus  are  united  by  a 
continuous  '  glover's  '  suture  of  catgut ;  at  the  lower  part  of  the  incision  the  omentum 
is  shown  drawn  down  over  the  abdominal  viscera. 


any  stitch  before  firm  union  has  occurred ;  we  seldom  change  the  dressing 
until  the  tenth  day  after  the  operation,  unless  button  sutures  have 
been  employed. 

Avoidance  of  Movement. — This  should  be  provided  for  in  all 
wounds.  In  operations  on  the  extremities,  a  suitable  splint  must  be 
applied  to  control  the  movements  of  the  neighbouring  joints,  and  this 
should  be  kept  on  for  about  a  week  or  ten  days.  In  operations  upon  the 
abdomen,  a  firm  binder  will  usually  ensure  rest,  if  the  patient  be  forbidden 


TREATMENT  OF   INCISED   WOUNDS 


145 


to  sit  up.  In  operations  about  the  neck,  it  is  usual  to  put  on  an  extra 
amount  of  dressing,  which  is  firmly  fixed  with  a  bandage,  so  that,  when  the 
deeper  part  becomes  stiffened  by  the  dried  blood,  and  is  supported  by 
the  large  mass  of  dressing  outside  it,  it  practically  forms  a  splint  for  the 
head  and  neck ;  some  surgeons  employ  a  specially  moulded  splint  of 


FIG.  46. — SUTURE  OF  AN  ABDOMINAL  WOUND  IN  FOUR  LAYERS. — Second  layer. 
The  abdominal  muscles  have  been  drawn  together  by  a  series  of  interrupted  sutures 
inserted  at  right  angles  to  the  direction  of  the  muscular  fibres. 

poroplastic  material  or  guttapercha,  but  this  is  rarely  necessary  except 
in  young  children. 

Avoidance  of  Irritation. — Care  must  also  be  taken  to  prevent 
irritation  of  the  wound  by  antiseptic  solutions  or  dressings ;  but  if  a 
wound  be  not  dressed  until  it  has  healed,  as  is  our  usual  rule,  there  will 
of  course  be  no  irritation  resulting  from  antiseptic  lotions.  The  chief 
point  of  importance,  therefore,  centres  in  the  choice  of  the  dressings, 


146 


WOUNDS 


which  must  not  exert  any  chemical  or  mechanical  irritation.  Care  must 
be  taken  to  see  that  the  gauze  placed  next  the  wound  does  not  contain 
any  soluble  irritating  antiseptic  substance ;  the  mere  presence  of  the 
gauze  over  a  wound,  the  edges  of  which  have  been  brought  together 


FIG.  47. — SUTURE  OF  AN  ABDOMINAL  WOUND  IN  FOUR  LAYERS. — Third  layer. 
The  anterior  layer  of  the  sheath  of  the  rectus  is  closed  by  a  continuous  suture  of 
fine  silk. 


accurately,  does  not  interfere  with  healing  by  first  intention,  particularly 
if  the  wound  be  left  undisturbed  for  a  week  or  ten  days.  When  silver 
stitches  are  used,  their  ends  are  prone  to  become  entangled  in  the  gauze, 
and  any  movements  of  the  patient  may  drag  upon  them ;  this  can  be 
avoided  by  interposing,  between  the  line  of  incision  and  the  gauze  dressing, 
a  narrow  strip  of  sterilised  Lister's  protective  oiled  silk  (see  p.  51),  thin 


TREATMENT  OF   INCISED  WOUNDS 


147 


sheet  rubber,  or  tinfoil.  When  button  stitches  are  used,  each  button 
should  also  be  covered  with  a  piece  of  this  material,  but  care  must  be 
taken  that  the  dressing  overlaps  the  latter  for  a  considerable  distance  in 
all  directions  ;  if  not,  sepsis  may  spread  in  beneath  it. 


FIG.  48. — SUTURE   OF  AN  ABDOMINAL  WOUND  IN   FOUR  LAYERS. — Fourth  layer. 
The  incision  in  the  skin  is  being  closed  by  a  continuous  silk  suture. 

Drainage. — After  the  operation  has  been  performed,  the  question  of 
drainage  arises.  When  Lord  Lister  began  his  antiseptic  work  he  laid 
great  stress  on  the  use  of  drainage  ;  at  that  time  one  of  the  results  of  the 
free  application  of  carbolic  acid  to  wounds  was  a  marked  exudation  of 
serum,  which,  if  not  allowed  to  escape,  distended  the  wound  and  some- 
times caused  considerable  trouble  in  healing.  But  with  the  introduction 
of  sublimate  solution  and  the  avoidance  of  carbolic  acid  in  the  wound, 
the  conditions  underwent  a  change,  and  at  the  present  time  it  is  only 


148 


WOUNDS 


comparatively  seldom  that  drainage  is  required.  In  order  to  dispense 
with  drainage  safely  it  is  essential  to  arrest  aU  bleeding  before  the  wound 
is  closed,  and  then  to  bring  the  deeper  parts  of  it  into  apposition  so  that 
there  shall  be  no  '  dead  space '  into  which  bleeding  may  take  place  subse- 


FIG.  49. — SUTURE  OF  THE  ABDOMINAL  WALL  IN  Two  LAYERS. — All  the  structures 
from  the  peritoneum  to  the  superficial  layer  of  the  sheath  of  the  rectus  are  drawn 
together  by  stout  silk  sutures ;  the  skin  is  then  closed  with  a  silk  suture  as  in 
Fig.  48. 


quently.  This  may  be  done  in  some  cases  by  buried  sutures  (see  p.  137), 
as,  for  instance,  after  laparotomy  (the  most  suitable  form  of  stitch  for 
which  is  shown  in  Figs.  45-50),  exposure  of  the  kidney,  etc. ;  but  in 
ordinary  cases  we  consider  that  efficient  pressure  applied  outside  the 
wound  suffices.  It  is  only  in  certain  cases  of  incised  wounds  made  by 
the  surgeon  that  it  is  impossible  to  obliterate  any  cavity  in  the  wound  ; 
in  them,  drainage  tubes  are  required. 


TREATMENT  OF  INCISED  WOUNDS  149 

Cases   calling   fop  Drainage. — The    following    are    the    chief   con- 
ditions in  which  drainage  seems  desirable  : 

(1)  In  amputation  wounds. — After  amputation  it  would  not  do  to  keep 

the  flaps  firmly  pressed  together  for  fear  of  interfering  with  their 
blood-supply,  while  it  would  be  equally  hurtful  to  allow  blood  to 
distend  them,  and  possibly  lead  to  gangrene.  Therefore  it  seems 
advisable  to  introduce  a  drainage-tube  in  all  cases  of  amputation. 

(2)  When  a  cavity  is  left. — For  example,  after  excision  of  one-half  of 

the  thyroid  gland  a  cavity  is  left  into  which  bleeding  is  very  apt 
to  occur,  for  pressure  cannot  be  applied  satisfactorily  without 
interfering  with  the  trachea  ;  in  these  and  similar  cases  the 


FIG.  50. — SUTURE  OF  MUSCLES  BY  THE  MATTRESS  STITCH. — This  suture  is  used 
when  the  muscular  fibres  have  been  divided  transversely. 

temporary  use  of  a  drainage-tube  is  advisable.  A  drainage- 
tube  is  also  of  service  when  the  wound  is  very  extensive,  as 
after  removal  of  the  breast  for  cancer. 

(3)  When  there  is  oozing  which  cannot  be  stopped  by  ligature — e.g.  in 

abdominal  operations,  where  a  large  number  of  adhesions  have 
been  broken  down  and  there  is  a  definite  liability  to  the 
formation  of  a  haematoma. 

(4)  In  very  fat  people. — Wounds  in  very  stout  people  seem  to  fill  with 

oil,  and  this  apparently  interferes  with  the  proper  healing  of 
the  wound  ;  in  these  cases  also  it  is  well  to  employ  drainage. 

(5)  When  there  is  a  risk  of  sepsis. — Drainage  should  always  be  employed 

when  a  sinus  or  ulcer  is  present  at  the  seat  of  operation,  and 
also  in  compound  fractures,  lest  the  attempt  to  disinfect  them 
prove  unsuccessful. 


150 


WOUNDS 


When  a  drainage-tube  is  introduced  it  need  not  extend  the  whole 
length  of  the  wound  so  long  as  it  passes  into  the  deeper  parts  of  it ;  and  it  is 
well,  in  order  to  avoid  the  risk  of  displacement  of  the  tube,  to  stitch  the 
outer  end  to  the  edges  of  the  skin  after  cutting  the  tube  flush  with  the 
surface.  Drainage-tubes  need  not  be  left  in  a  wound  longer  than  three 
or  four  days  unless  sepsis  occurs.  If  it  be  desired  to  leave  a  particularly 
small  scar,  a  few  strands  of  horsehair  will  suffice  to  form  a  fine  capillary 
drain. 

Drainage  should  be  carried  out  by  means  of  tubes ;  the  gauze  wicks 
which  are  so  much  used  at  the  present  time  are  objectionable  and 
inefficient. 


??ooo  oooo  O  O  O 

oo 


O 


FIG.  51. — SIZES  OF  DRAINAGE-TUBES. — There  is  no  standard  gauge  for  these, 
each  instrument-maker  numbering  them  independently.  The  numbers  quoted  in  this 
book  refer  to  drainage  tubes  whose  cross-section  is  represented  in  this  figure. 


Dressings. — After  having  completed  the  operation,  stitched  up  the 
wound,  and  arranged  for  drainage  if  necessary,  the  next  point  is  the 
application  of  the  dressings.  Before  the  dressings  are  applied,  the  blood 
should  be  squeezed  out  of  and  removed  from  the  neighbourhood 
of  the  wound,  care  being  taken  to  wash  away  from  the  wound  and 
not  towards  it.  During  this  process,  it  is  well  to  protect  the  wound 
from  infection  by  means  of  a  piece  of  cyanide  gauze  soaked  in  i  in  2000 
sublimate  solution,  which  is  removed  just  before  the  dressing  is  applied. 
At  the  present  time  the  tendency  is  to  use  dry  dressings,  which  possess 
two  great  advantages.  In  the  first  place,  the  blood  dries  quickly  in  them, 
and  does  not  therefore  form  a  suitable  soil  for  the  development  of  organ- 
isms ;  and  consequently,  if  the  dressings  be  not  quite  aseptic  or,  the 
skin  be  not  completely  disinfected,  the  organisms  may  be  unable  to 
grow  and  reach  the  wound.  In  the  second  place,  the  dried-up  blood- 
stained dressings  adhere  to  the  skin  and  form  a  sort  of  splint,  which 
keeps  the  edges  of  the  wound  at  rest. 


TREATMENT  OF  INCISED  WOUNDS  15! 

Lister's  Cyanide  Gauze. — The  most  universally  applicable  and  most 
satisfactory  dressing  yet  introduced  is  the  latest  dressing  proposed  by 
Lord  Lister — viz.  gauze  impregnated  with  the  double  cyanide  of  mercury 
and  zinc.  Certain  precautions  must  be  taken  in  using  this  dressing. 
As  it  comes  from  shops  it  is  not  sterile,  and  must  be  disinfected  before 
use  (see  p.  97).  Even  when  it  has  been  sterilised  in  an  autoclave  it  is 
well  to  moisten  the  layers  applied  next  to  the  skin  with  I  in  60  or  I  in  40 
carbolic  acid  or  I  in  2000  perchloride  of  mercury  solution,  for  two  reasons  : 
in  the  first  place,  the  wet  gauze  absorbs  the  blood  better  and  diffuses  it 
more  evenly  through  the  dressing  ;  while,  in  the  second  place,  the  double 
cyanide  dissolves  so  slowly  in  the  blood  that  dust  falling  upon  the  wound 
may  have  time  to  infect  it  before  the  cyanide  has  had  time  to  become 
dissolved  by  the  blood,  especially  if  a  drainage-tube  has  been  used. 
Outside  the  gauze  we  apply  either  salicylic  or  cyanide  wool,  sterilised  in 
an  autoclave  if  possible ;  large  quantities  are  used,  and  a  wide  area  of 
skin  all  around  the  wound  should  be  covered.  Besides  being  extensive 
in  area,  the  dressing  should  be  of  considerable  thickness,  some  twelve 
to  twenty  folds  of  gauze  being  employed. 

Pressure. — After  applying  the  first  few  folds  of  gauze,  it  is  well,  in 
some  cases — e.g.  operations  for  hernia — to  place  over  the  wound  sterile 
sponges  wrung  out  of  the  antiseptic,  so  as  to  approximate  the  deeper  parts 
and  prevent  the  formation  of  a  cavity.  Outside  the  sponges  more  gauze 
is  applied,  and  outside  this  again  a  mass  of  sterilised  salicylic  or  cyanide 
wool.  Salicylic  wool  does  not  absorb  well,  and  the  object  in  employing 
it  is  not  so  much  to  furnish  an  additional  antiseptic  layer  (though  that 
is  an  important  point)  as  to  provide  a  material  which,  while  permitting 
evaporation,  leads  to  a  diffusion  of  blood  and  serum  over  a  considerable 
area  of  the  cyanide  dressings.  As  a  matter  of  fact,  however,  the  dis- 
charge from  the  wound  is  usually  slight  when  sponge  pressure  is  employed, 
and  seldom  reaches  the  wool  at  all.  Bandages  are  applied  outside  the 
wool,  specially  firm  pressure  being  brought  to  bear  over  the  sponges. 

When  to  change  Dressings. — A  dressing  of  this  kind  is  usually 
left  undisturbed  for  about  ten  days,  unless  there  be  some  reason  for 
changing  it,  such  as  discomfort,  fever,  the  presence  of  a  drainage  tube, 
or  any  suspicion  of  sepsis.  It  is  a  mistake  to  change  a  dressing  soon 
after  the  operation  unless  it  be  really  necessary,  because  the  dressing 
adheres  to  the  skin,  and,  in  pulling  it  off,  the  union  of  the  deeper  parts  may 
be  disturbed,  and  bleeding  may  even  occur  into  them.  The  following 
are  the  principal  cases  in  which  an  early  change  of  dressing  is  called 
for: 

(i)  In  some  cases,  the  dressings  become  hard  and  uncomfortable 
as  they  dry,  and  in  sensitive  patients  therefore  it  may  be 
advisable  to  change  them  at  the  end  of  three  or  four  days  ;  the 
second  dressing  never  becomes  so  hard  and  uncomfortable  as 
the  first. 


I52  WOUNDS 

(2)  When  the  amount  of  oozing  from  the  wound  is  excessive.     The 

old  rule  that  dressings  required  changing  very  soon  after  discharge 
showed  itself  through  them  is  not  now  applicable  ;  as  a  matter 
of  fact,  it  is  not  uncommon  for  a  little  blood  to  appear  on  the 
outer  surface  of  a  dressing  such  as  that  described  above  within 
a  few  hours  after  the  operation  ;  but  this  dries  up  quickly 
and  does  not  form  a  suitable  medium  for  the  growth  of 
bacteria,  because  the  double  cyanide  salt  is  a  powerful  inhibitory 
agent,  and,  being  only  slightly  soluble,  is  not  washed  out  by  the 
first  blood  which  passes  through  the  dressing.  All  that  is  neces- 
sary is  to  wet  the  soiled  portion  with  I  in  20  carbolic  solution, 
to  apply  fresh  wool  outside  this,  and  to  secure  it  by  another 
bandage. 

(3)  When  a  drainage-tube  has  been  inserted,  the  dressings  must  be 

changed  at  the  end  of  two  or  three  days  in  order  to  remove  it ; 
if  the  wound  be  large,  the  discharge  through  the  tube  may  be 
sufficiently  copious  to  necessitate  a  change  of  dressing  at  the  end 
of  twenty-four  or  forty-eight  hours. 

(4)  If  the  temperature  rise  and  remain  over  100°  F.  for  more  than 

twenty-four  hours  after  the  operation,  or  if  there  be  much 
pain,  the  dressing  must  be  removed  to  see  if  anything  be  wrong 
with  the  wound. 

How  to  change  Dressings. — When  the  dressings  are  changed  at  the  end 
of  about  ten  days,  the  wound  is  usually  soundly  healed  ;  the  stitches  are 
then  taken  out,  and  a  small  piece  of  gauze  or  salicylic  wool  is  fixed  over 
the  line  of  incision  for  a  few  days  by  means  of  collodion.  In  changing 
dressings  it  is  well  to  employ  a  i  in  2000  sublimate  solution  to  wash  the 
wound,  except  in  operations  in  the  axilla,  the  perineum,  or  about  the 
pubes,  etc.,  where,  on  account  of  the  proximity  of  hairy  parts,  it  is  advisable 
to  wash  the  skin  around  the  wound  with  a  I  in  20  carbolic  lotion.  The 
region  of  the  wound  should  be  surrounded  by  towels  wrung  out  of  an 
antiseptic  solution,  so  that  the  bedclothes  cannot  come  into  contact  with 
the  wound,  the  instruments,  or  the  surgeon's  hands.  The  latter  are 
disinfected  as  for  an  operation  (see  p.  101).  The  wound  should  be  swabbed 
over  gently,  but  thoroughly,  with  the  antiseptic  solution.  Should  the 
wound  be  not  quite  healed,  or  should  it  seem  advisable  to  leave  any  of  the 
stitches  in  place  for  some  time  longer  on  account  of  tension  upon  the 
edges,  a  dressing  may  be  applied  similar  to  that  put  on  immediately  after 
operation  (see  p.  150),  the  only  difference  being  that  the  sponges  need  not 
be  employed.  In  breast  cases,  for  instance,  where  a  large  amount  of  skin 
has  been  taken  away,  it  is  often  advisable  to  change  the  first  dressing 
before  the  end  of  the  first  week,  in  order  to  remove  some  of  the  stitches  ; 
the  remaining  stitches  may  then  be  left  for  another  week. 

After-progress  of  the  Wound. — It  will  be  found  that  neither  local 
nor  constitutional  disturbance  follows  operations  conducted  with  the 

j    iG    zf^JJr- 


TREATMENT  OF  INCISED   WOUNDS  153 

precautions  recommended  above.  After  a  very  severe  operation,  the 
temperature  is  at  first  sub-normal,  the  patient  suffers  from  a  certain 
amount  of  shock  for  some  hours,  and  this  is  followed,  to  an  extent  closely 
corresponding  to  the  degree  of  shock,  by  a  certain  amount  of  reaction, 
so  that  next  day  the  temperature  may  rise  to  100°  or  even  to  101°  F. 
At  the  same  time,  however,  the  pain  complained  of  immediately  after 
the  operation  subsides,  and  there  is  no  fresh  development  of  it,  as  would 
be  the  case  were  the  temperature  due  to  sepsis.  In  the  course  of  another 
twelve  to  twenty-four  hours  the  temperature  falls  rapidly  to  normal. 

Treatment  without  Antiseptics. — The  other  plan,  to  which  we 
have  already  referred  (see  p.  99),  in  which  attempts  are  made  to  keep 
wounds  aseptic  without  the  use  of  antiseptic  lotions  and  dressings, 
does  not  yield  in  practice  the  uniformly  good  results  which  are  obtained 
by  the  method  just  described.  In  it  the  use  of  antiseptics  is  entirely 
avoided  dunng  the  actual  performance  of  the  operation,  and  in  the  after- 
treatment  of  the  wound.  The  skin  is  purified,  and  the  hands  of  the 
assistants  and  the  operator  are  disinfected  much  in  the  manner  already 
described  (see  p.  150).  The  instruments  are  boiled,  but  are  not  afterwards 
immersed  in  antiseptics,  and  no  antiseptic  solution  is  at  hand  in  which 
to  rinse  the  hands  or  the  sponges.  The  sponging  of  the  wound  is  done 
with  pieces  of  wool  or  gauze  disinfected  by  heat  and  used  dry,  and  the 
towels  placed  around  the  operation  area  are  also  dry,  and  have  been 
previously  disinfected  by  heat.  There  is  therefore  no  possibility  of 
correcting  any  accident  that  may  happen  during  the  operation,  such  as 
dust  falling  on  the  towels,  or  the  unobserved  contact  of  the  hand  with 
any  object  that  has  not  been  disinfected.  The  dressings  consist  for  the 
most  part  of  simple  absorbent  unmedicated  gauze  and  wool  which  have 
been  disinfected  by  heat,  the  drum  or  bag  in  which  they  have  been 
disinfected  being  opened  at  the  side  of  the  patient  by  the  surgeon  himself. 
It  is  obvious  that  the  greatest  care  is  required  in  handling  these  if  accidental 
contamination  is  to  be  avoided.  In  the  Listerian  plan,  which  we  recom- 
mend, any  such  accidental  contamination  may  be  automatically  remedied 
if  it  should  occur,  because  everything  is  being  frequently  soaked  in  an 
antiseptic  solution  ;  in  the  so-called  '  aseptic  '  plan  there  is  no  corrective 
for  these  accidents  at  all,  and,  consequently,  experience  shows  that  the 
results  obtained  by  its  means  are  inferior  to  those  obtained  by  the  other 
method. 

There  is  no  doubt  that  in  theory  it  ought  to  be  possible  to  carry  out 
this  aseptic  plan,  and  if  it  were  found  in  practice  that  the  use  of  antiseptics 
gave  rise  to  great  irritation  in  wounds,  the  employment  of  such  a  cumbrous 
and  troublesome  method  as  this  would  be  justified.  As  a  matter  of  fact, 
however,  the  irritation  of  wounds  from  such  antiseptics  as  we  recommend 
is  inappreciable,  and  there  is  no  reason  for  making  use  of  this  troublesome 
method,  particularly  as  the  results  obtained  by  it  are  not  so  good  as  that 
obtained  by  using  antiseptics.  The  aseptic  method  can  only  be  carried 


154  WOUNDS 

out  by  a  skilled  and  experienced  bacteriologist,  with  all  the  resources  of 
a  large  and  well-equipped  hospital  at  his  command.  In  private  practice, 
it  is  almost  impossible  to  carry  it  out  in  all  its  details  ;  moreover,  it  may 
prove  positively  harmful,  since  a  single  error  may  invalidate  the  whole 
proceeding,  and  no  corrective  is  possible.  Prolonged  experience  of  the 
Listerian  methods  has  failed  to  convince  us  of  any  danger  in  or  objection 
to  their  use. 

Causes  of  Failure  to  secure  Healing  by  First  Intention. — 
When  all  the  steps  of  the  antiseptic  method  have  been  rigidly  adhered 
to,  healing  by  first  intention  almost  invariably  follows.  When  it  does 
not  occur,  it  is  generally  because  some  error  has  been  committed  in  the 
management  of  the  case,  which  has  led  to  the  occurrence  of  sepsis.  Some- 
times, however,  union  may  fail,  at  any  rate  in  part,  notwithstanding 
that  the  wound  remains  aseptic.  The  most  common  cause  of  this  is  the 
accumulation  of  serum  in  the  deeper  parts  of  the  wound ;  in  these  cases 
a  drainage-tube  should  have  been  employed.  If  accumulation  does  take 
place,  it  is  better  to  evacuate  the  serum  at  once  than  to  wait  in  the  hope  that 
it  will  be  absorbed ;  doubtless  absorption  sometimes  occurs,  but  in  the 
majority  of  cases  the  serum  will  find  its  way  out  along  the  line  of  incision. 
When,  therefore,  a  collection  of  fluid  in  the  wound  is  found  at  the  first 
dressing,  time  is  saved  by  opening  up  the  incision  with  a  pair  of  sinus 
forceps,  letting  out  the  fluid  and  introducing  a  small  drainage-tube, 
which  should  be  left  in  for  two  or  three  days.  The  fluid  is  serum  or 
altered  blood,  and  the  wound  closes  quickly  when  a  drainage-tube  is 
introduced  and  pressure  applied  outside. 

The  importance  of  putting  in  enough  sutures  to  prevent  gaping  of  a 
wound,  and  of  not  tying  them  too  tightly,  has  already  been  referred  to 
(see  p.  142).  If  too  few  sutures  have  been  employed,  the  tension  on  any 
individual  stitch  may  be  so  great  that  it  will  cut  its  way  through  the 
skin  and  allow  a  portion  of  the  wound  to  gape.  Movement  of  the  part 
may  also  interfere  with  primary  union.  In  other  instances  the  cause  of 
non-union  may  be  that  the  knife  has  been  held  obliquely  in  making  the 
skin  incision  ;  the  bevelled  edge  of  skin  thus  left  on  one  side  often  dies. 
In  the  majority  of  cases,  however,  when  union  fails,  it  is  owing  to  the 
presence  of  sepsis  ;  and  if  suppuration  occur  in  a  wound  made  by  the 
surgeon  through  unbroken  skin,  its  occurrence  must  be  ascribed  to  errors 
in  carrying  out  the  antiseptic  technique  and  not  to  the  method  itself. 
Whether  it  be  that  the  surgeon  has  used  impure  materials  for  his  ligatures 
or  stitches,  or  whether,  as  is  commonly  the  case,  he  or  his  assistants  have 
introduced  the  organisms  with  their  hands,  the  cause  of  failure  is  the 
same.  This  fact  cannot  be  too  widely  appreciated. 

Errors  which  may  be  made  in  carrying  out  the  antiseptic  treatment 
of  wounds  have  already  been  described,  but  it  is  impossible  to  point 
out  all  the  extraordinary  mistakes  which  are  committed  daily.  Unless 
the  surgeon  constantly  bears  in  mind  the  fact  that  nothing  that  has  not 


TREATMENT  OF  INCISED  WOUNDS  155 

been  made  aseptic  must  come  in  contact  either  with  the  wound,  the 
instruments,  or  the  hands  that  are  introduced  into  the  wound,  he  will 
be  sure  to  go  wrong  eventually.  A  preliminary  bacteriological  training 
is  of  incalculable  advantage,  for  with  it  the  manipulations  necessary  to 
secure  asepsis  become  automatic,  and  the  surgeon  is  thus  enabled  to 
concentrate  his  undivided  attention  upon  the  operation. 

Treatment  when  Sepsis  occurs.— The  onset  of  sepsis  is  indicated 
by  pain  and  throbbing  in  the  wound.  The  reactionary  temperature  com- 
monly met  with  after  severe  aseptic  operations,  instead  of  falling  in  from 
twenty-four  to  thirty-six  hours,  continues  to  rise,  and  all  the  symptoms  of 
pyrexia  set  in.  When  this  febrile  condition  has  set  in,  the  wound  should 
be  examined  at  once,  and  if  red,  tender,  or  swollen,  should  be  opened  up 
and  proper  drainage  provided.  The  degree  to  which  the  wound  should  be 
opened  up  must  be  judged  separately  for  each  case,  as  it  frequently  happens 
that  the  suppuration  is  due  to  an  organism  of  low  virulence,  and  the 
removal  of  a  stitch,  followed  by  the  insertion  of  a  small  drainage-tube 
at  the  most  dependent  part  of  the  wound  will  suffice  to  meet  all  the 
requirements  of  the  case.  It  would  be  a  mistake  to  lay  open  the  entire 
wound  because  there  is  slight  infection  at  one  point. 

As  a  rule  it  is  not  advisable  to  wash  out  a  wound  in  this  condition, 
although  this  is  done  by  some  surgeons.  Washing  out  a  septic  wound 
with  antiseptics  will  not  arrest  the  infection,  and  it  can  only  irritate 
and  damage  the  inflamed  tissues,  and  possibly  precipitate  the  entrance  of 
micro-organisms  into  the  system.  Provided  there  be  a  free  exit  for  pus, 
it  is  best  not  to  wash  out,  squeeze  or  irritate  the  wound  in  any  way. 
The  only  exception  to  this  rule  is  in  large  cavities,  when  there  is  reason  to 
believe  that  the  symptoms  are  mainly  due  to  septic  intoxication — that  is 
to  say,  absorption  of  poisonous  chemical  products,  and  not  true  general 
bacterial  infection.  Under  such  circumstances  it  is  well  to  wash  away 
the  septic  fluid  in  the  wound  with  sterilised  saline  solution  or  with  a 
solution  of  peroxide  of  hydrogen  (10  vols.).  This  is  not  done  with  the 
view  of  killing  bacteria,  but  of  removing  the  poisonous  chemical  products 
which  are  being  absorbed,  and  are  producing  the  symptoms.  It  is  well 
to  go  on  with  the  antiseptic  dressings  already  described  (see  p.  150)  ; 
they  should  be  changed  once  daily,  or  oftener,  but  there  is  no  need  to 
continue  the  irrigation  after  all  the  decomposing  blood-clot  has  been 
washed  away. 

When  no  general  infection  has  occurred,  or  is  about  to  take  place,  the 
temperature  falls,  and  the  other  general  and  local  conditions  improve 
within  a  few  hours  after  a  free  exit  has  been  provided  for  the  discharge. 
In  the  course  of  a  few  days  suppuration  ceases  and  the  discharge  becomes 
serous ;  if  everything  goes  well,  the  drainage-tube  may  be  left  out  in 
from  ten  to  fourteen  days.  When,  on  the  other  hand,  the  temperature 
keeps  up  and  the  other  symptoms  continue,  the  suspicion  is  aroused  either 
that  there  is  some  recess  in  the  wound  from  which  the  discharge  is 


156  WOUNDS 

not  escaping  properly,  or  that  some  general  infection  is  occurring.  In 
either  case  the  wound  must  be  opened  up  freely  and  cleansed  and  all 
recesses  must  be  exposed.  When  retention  of  the  discharge  is  not 
sufficient  to  account  for  the  general  symptoms,  the  wound  should  be 
sponged  out  with  undiluted  carbolic  acid.  In  some  cases  the  surgeon 
may  even  venture  to  scrape  away  the  granulation-tissue  with  a  sharp 
spoon,  but  in  doing  this  there  is  always  a  certain  risk  of  forcing  organ- 
isms into  the  circulation.  One  of  Barker's  flushing  spoons  (see  Fig.  52) 
should  be  employed,  the  fluid  used  for  irrigation  being  a  i  in  4000 
sublimate  solution;  when  the  scraping  is  complete,  liquefied  carbolic 
acid  is  swabbed  over  the  entire  surface  of  the  wound.  After  this  has 
been  done,  the  wound  should  be  packed  with  cyanide  gauze  and  made 
to  heal  by  granulation  from  the  bottom,  the  packing  being  renewed 
once  or  twice  daily  if  the  suppuration  persist.  If  this  procedure  be 
followed  by  a  fall  in  the  temperature  and  an  amelioration  of  the  general 
symptoms,  it  may  be  possible  to  discontinue  the  packing  in  three  or 


FIG.  52. — FLUSHING  CURETTE. — The  handle  of  the  curette  is  provided  with  a 
thumb-screw  so  that  it  can  be  moved  along  the  instrument,  and  give  greater  purchase 
if  required.  In  the  small  upper  figure  the  sharp  end  of  the  curette  is  shown  full  size. 

four  days  and  to  stitch  up  the  edges  of  the  wound  again  after  introducing 
a  drainage-tube. 

When  the  occurrence  of  rigors  and  sudden  elevations  of  temperature 
lead  one  to  suspect  pyaemia,  it  is  important  to  look  carefully  for  any 
thrombosed  veins  when  opening  up  the  wound ;  and  should  any  be  found, 
the  main  vein  above  the  thrombosed  area  should  be  ligatured,  and  a 
portion  excised  in  order  to  cut  off  the  local  source  of  infection  from  the 
general  circulation.  When  the  constitutional  symptoms  persist  in  spite 
of  this  energetic  local  treatment,  nothing  remains  but  to  treat  the 
patient  on  the  lines  recommended  for  pyaemia  (see  p.  193).  When  there 
is  diffuse  cellulitis  around  the  wound,  constant  irrigation  (see  p.  32)  may 
be  employed,  to  wash  away  the  septic  material  as  soon  as  it  is  formed. 
Incisions  into  the  inflamed  area  may  be  necessary  (see  p.  31). 

When  the  wound  has  become  covered  with  healthy  granulations,  the 
healing  process  can  often  be  accelerated  by  secondary  suture.  Strong 
silkworm-gut  stitches  should  be  passed  deeply  into  the  tissues  on  either 
side  of  the  wound  and  should  be  tied  firmly,  but  not  too  tightly ;  a  space 
should  be  left  between  the  stitches  at  one  end  of  the  incision  for  a  drainage- 
tube.  Such  a  suture  as  this  necessarily  involves  less  free  drainage  than 


TREATMENT  OF  INCISED  WOUNDS  157 

before,  and  for  a  day  or  two  afterwards  there  may  be  slight  rises  of 
temperature. 

Treatment  of  Wounds  in  which  the  Edges  are  not  brought 
together. — It  is  important  that  organisms  should  be  excluded  from 
these  wounds  also,  and  if  this  be  successfully  accomplished,  and  the 
part  kept  absolutely  at  rest  and  not  irritated  by  the  dressings,  the 
space  between  the  edges  fills  up  with  blood,  and  healing  by  blood-clot 
will  occur.  To  obtain  this  result,  similar  methods  and  dressings  should 
be  employed  to  those  used  when  the  edges  have  been  brought  together, 
but,  in  order  to  protect  the  blood-clot  from  the  irritation  of  the  dressings, 
a  piece  of  Lister's  oiled  silk  protective  or  thin  sterilised  rubber  or  tinfoil, 
somewhat  larger  than  the  wound,  should  be  interposed ;  outside  this  a 
large  gauze  and  wool  dressing  is  applied.  When  the  wound  is  large, 
healing  by  blood-clot  generally  occurs  to  a  considerable  extent,  and  then 
a  small  part  in  the  centre  undergoes  a  certain  amount  of  granulation 
before  complete  cicatrisation  takes  place. 

Thierseh's  Skin-grafting  in  Fresh  Wounds. — Since  healing  by  blood- 
clot  is  a  slow  process,  and  is  always  open  to  the  risk  of  accidental  con- 
tamination of  the  wound,  Thierseh's  skin-grafting  is  often  employed, 
as  it  is  a  quicker  method  of  obtaining  healing.  If  it  be  carried  out  im- 
mediately at  the  end  of  the  operation  in  which  the  wound  has  been  made, 
a  good  result  will  be  obtained  in  most  cases,  and  healing  will  occur  almost 
as  rapidly  as  in  union  by  first  intention,  while  the  contraction  which 
follows  granulation  will  be  avoided  almost  entirely.  The  process  is 
identical  with  that  described  on  p.  53,  except  that  the  grafts  are  applied 
direct  to  the  fresh  surface  of  the  wound,  which  does  not  require  to  be 
scraped.  When  the  operation  has  been  very  extensive,  and  the  patient 
is  very  collapsed,  it  may  be  advisable  to  defer  the  skin-grafting  for  a 
short  time  ;  in  these  cases  the  blood-clot  is  removed  from  the  surface  of 
the  wound  after  about  ten  days,  and,  when  the  oozing  has  been  arrested, 
the  grafts  are  applied  in  the  usual  manner.  It  might  be  supposed  that 
grafts  would  not  adhere  well  to  non-granulating  tissues,  but  they  do ;  and 
immediate  skin-grafting  is  a  very  valuable  help  in  obtaining  a  good 
result  where  so  much  skin  has  to  be  removed  that  a  large  open  wound 
would  otherwise  be  left. 

Plastic  Operations. — Where  the  cutaneous  loss  is  not  excessive,  and 
the  skin  in  the  neighbourhood  is  fairly  lax,  the  interval  between  the 
edges  of  the  wound  may  be  obliterated  by  means  of  a  plastic  operation, 
which  is  an  operation  performed  with  the  view  of  covering  in  some 
congenital  or  acquired  defect  in  the  skin  or  mucous  membrane.  Here 
we  shall  only  deal  with  the  covering-in  of  defects  left  after  an  operation 
in  which  the  edges  of  the  wound  cannot  be  brought  together.  The  plastic 
operations  in  connection  with  other  affections  will  be  dealt  with  in 
connection  with  those  affections. 

In  such  a  simple  form  of  defect  as  an  oval  wound,  the  steps  necessary 


158  WOUNDS 

to  bring  the  edges  into  apposition  are  generally  very  simple.  If  the 
skin  around  the  wound  be  undercut  widely  enough  to  allow  the  elasticity 
of  the  skin  sufficient  play,  a  very  extensive  defect  may  be  repaired  thus. 
In  removal  of  the  breast,  for  example,  an  oval  gap  measuring  six  inches 
or  more  in  its  transverse  diameter  may  be  closed  by  undermining  the 
surrounding  skin. 

The  best  way  is  to  proceed  as  follows.  In  small  wounds,  the  knife 
is  carried  between  the  superficial  fat  and  the  deep  fascia ;  in  large  ones, 
it  should  be  swept  between  the  deep  fascia  and  the  muscle.  By  this 
means  the  skin  and  fascia  are  raised  from  the  deeper  parts  for  such  a 
distance  around  the  wound  as  the -surgeon  judges  will  be  necessary  to 
allow  the  edges  to  come  together.  The  undermining  should  be  most 
extensive  opposite  the  shorter  diameter  of  the  oval,  and  should  be 
carried  on  until  the  edges  of  the  wound  can  be  brought  easily  into  contact 
by  pulling  upon  them.  In  raising  these  flaps  care  must  be  taken  to 
direct  the  edge  of  the  knife  towards  the  deeper  parts  and  not  towards  the 
skin  ;  failure  to  observe  this  precaution  is  apt  to  result  in  scoring  of  the 
flap,  and,  as  the  blood-vessels  which  supply  the  skin  ramify  in  the  sub- 
cutaneous fat,  the  blood-supply  to  the  edges  of  the  wound  might  be  cut 
off  and  sloughing  might  ensue. 

The  undermining  must  be  free  enough  to  allow  the  edges  of  the 
wound  to  come  together  without  such  tension  as  to  endanger  the  circula- 
tion in  the  flaps.  Flaps  that  have  been  dragged  together  after  insuffi- 
ciently free  undercutting  will  become  white  on  putting  in  the  stitches, 
and  the  circulation  in  them  will  not  be  restored  ;  in  such  a  case,  there- 
fore, it  will  be  necessary  to  carry  the  undermining  further,  so  as  to  allow 
of  the  flaps  being  brought  together  without  being  permanently  blanched. 
If  at  first  there  be  a  little  whiteness  in  the  immediate  vicinity  of  the  stitch, 
it  will  disappear  in  a  few  minutes  when  the  tension  is  not  too  great. 
Deep  stitches  and,  if  necessary,  button  stitches  should  be  used  to  relax 
the  edges  in  order  that  there  may  be  no  tension  upon  the  actual  line  of 
union  (see  p.  139). 

Angular,  quadrilateral,  or  irregular-shaped  wounds  require  one  of 
the  plastic  operations  proper  for  their  closure.  A  small  quadrilateral 
defect  is  easily  closed  by  making  straight  incisions  which  extend  two 
corresponding  sides  of  the  parallelogram  into  the  healthy  skin  on  one 
side  ;  for  example,  in  Fig.  53  the  side  AB  is  extended  to  b  and  CD  to  d. 
The  flap  BDdb,  which  ought  to  be  about  double  the  length  of  the  side 
AB,  is  then  dissected  up  along  with  the  subcutaneous  tissue  ;  the  elasticity 
of  the  skin  then  allows  the  flap  to  be  stretched  with  comparatively  slight 
tension,  so  that  the  point  B  may  be  stitched  to  the  point  A,  and  the 
point  D  to  the  point  C. 

When  the  quadrilateral  defect  is  large,  it  can  be  closed  by  making 
similar  incisions  on  the  opposite  side  also  ;  for  example,  in  Fig.  53,  by 
extending  the  side  AB  both  to  b  and  to  a,  and  CD  to  both  d  and  c.  The 


TREATMENT  OF   INCISED  WOUNDS  159 

two  flaps,  ACca  and  BDdb,  are  dissected  up  and  can  be  made  to  meet 
in  the  middle  of  the  defect. 

Where  the  defect  is  triangular,  say  an  equilateral  triangle,  and  the  raw 
area  is  small,  it  may  suffice  to  make  an  incision  which  prolongs  one  side 
only,  the  extension  being  about  double  the  length  of  that  side  (see  Fig.  54). 
The  triangular  flap  thus  marked  out  is  dissected  up  along  with  the  fat, 
when  the  point  B  can  generally  be  stitched  to  the  point  A.  If,  however] 
the  defect  be  large,  the  sides  may  be  made  to  meet  by  forming  a  second 
similar  flap  on  the  other  side— that  is  to  say,  by  extending  one  side  in 
both  directions.  These  two  flaps,  will  then  meet  in  the  middle  line  and 
can  be  sewn  together  (see  Fig.  54). 

In  many  cases,  however,  especially  when  the  triangular  space  is  large, 


c  o 

FIG.  53.— How  TO  FILL  A  QUADRILATERAL  DEFECT  BY  MEANS  OF 


d 
PLASTIC 


OPERATION  —The  details  are  given  in  the  text.     On  the  left-hand  side  is  shown  the 
method  of  filling  a  small  defect,  on  the  right-hand  side,  a  large  one. 


FIG.  54. — How  TO  FILL  IN  A  TRIANGULAR  DEFECT  BY 
MEANS  OF  PLASTIC  OPERATION. — The  steps  of  the  operation 
are  given  in  the  text. 


FIG.  55. — How  TO  FILL  IN  A  TRIAN- 
GULAR DEFECT  BY  MEANS  OF  CURVED 
INCISIONS. — The  dotted  lines  represent 
the  curved  incisions. 


the  incisions  for  the  flaps  should  be  curved,  and,  in  the  case  of  irregular 
defects  much  better  results  will  be  obtained  by  the  use  of  curved  incisions 
than  by  straight  ones.  When  it  is  necessary  to  remove  the  lower  lip, 
this  is  usually  done  by  taking  out  a  V-shaped  piece,  the  apex  of  the  V 
being  towards  the  chin.  To  fill  up  the  gap  thus  made,  a  large  curved 
incision  should  be  made,  beginning  at  the  angle  of  the  mouth,  running 
down  over  the  jaw  on  to  the  neck,  and  curving  inwards  towards  the  upper 
part  of  the  larynx.  When  the  whole  lip  has  been  removed,  a  similar 
incision  is  made  on  each  side.  The  incision  goes  through  the  whole 
thickness  of  the  cheek  ;  when  it  passes  on  to  the  neck,  the  skin  and 
superficial  fascia  alone  are  dissected  up.  When  the  flaps  have  been 
raised  sufficiently,  the  curved  incisions  allow  them  to  slide  inwards,  so 
that  the  two  sides  of  the  triangular  defect  meet  in  a  vertical  line,  and 
may  be  stitched  together ;  a  few  points  of  suture  are  then  put  in  along 
the  curved  lines  of  incision  (see  Fig.  55). 


160  WOUNDS 

We  need  not  here  go  into  detail  as  to  the  covering-in  of  irregular 
defects,  or  of  those  in  special  situations  ;  they  are  dealt  with  in  their 
appropriate  places.  The  principle  to  which  we  wish  to  call  attention 
is  that,  when  the  surgeon  has  to  make  good  large  defects  of  skin,  curved 
incisions  will  enable  him  to  do  so  with  much  greater  ease  and  less  extensive 
dissection  than  if  straight  incisions  alone  were  employed. 

Use  of  Granulating-  Flaps. — When  the  defect  is  large  and  the  flaps 
to  be  turned  in  are  long  and  have  a  comparatively  narrow  base — in 
other  words,  when  the  blood-supply  must  necessarily  be  imperfect — it 
has  been  recommended  that  the  flap  should  be  dissected  up  but  left 
attached  at  each  end,  and  that  both  it  and  the  wound  should  be  allowed 
to  granulate  before  the  actual  transplantation  of  the  flap  takes  place. 
The  reason  for  this  is  that  the  flap  is  more  likely  to  retain  its  vitality  if 
it  be  made  in  this  manner,  while  new  blood-vessels  and  a  more  ample 
blood-supply  are  developed  during  the  process  of  granulation. 

The  flaps  are  usually  rectangular,  and  their  two  ends  are  not  de- 
tached. Parallel  incisions  are  made  down  to  the  deep  fascia,  and  then 
the  flap  is  undermined  throughout  its  whole  extent,  so  that  the  finger 
can  be  passed  under  it  hi  all  directions.  A  piece  of  sterilised  protective, 
sheet  rubber  or  tinfoil  is  then  inserted  between  the  under  surface  of  the 
flap  and  the  deeper  structures,  and  this  is  kept  in  place  for  ten  days,  when 
the  new  vascular  supply  will  have  developed ;  one  end  of  the  flap  is 
then  divided,  and  the  latter  turned  in  so  as  to  cover  the  defect.  This 
method  certainly  overcomes  great  difficulties  with  regard  to  the  nutrition 
of  the  flaps,  but  cases  in  which  such  elaborate  measures  are  necessary 
are  usually  more  successfully  treated  by  Thiersch's  skin-grafting. 

Occurrence  of  Sepsis  in  Open  Wounds. — Should  these  wounds  become 
septic,  the  results  are  not  usually  very  serious,  unless  the  wound  com- 
municates with  a  cavity  in  the  bone  or  with  the  interior  of  a  joint,  etc.  ; 
the  wound  is  widely  open,  and  therefore  the  septic  material  readily  flows 
away  into  the  dressing,  and  only  a  small  amount  of  the  toxins  is  absorbed. 
Nevertheless,  if  the  wound  be  large,  the  temperature  rises  at  first,  and  a 
varying  degree  of  traumatic  fever  occurs,  while  the  edges  of  the  wound 
become  swollen,  red,  and  painful,  and  hi  the  course  of  two  or  three  days 
its  surface  becomes  covered  with  a  layer  of  granulation-tissue. 

Treatment. — As  soon  as  it  is  thought,  from  the  rise  of  temperature 
and  other  symptoms,  that  sepsis  has  occurred,  the  dressings  should  be 
removed,  the  surface  of  the  wound  thoroughly  cleansed,  and  any  adherent 
blood-clot  removed.  When  the  symptoms  are  not  severe,  the  cyanide 
dressings  may  be  continued,  but  they  should  be  changed  daily,  and  the  sur- 
face of  the  wound  should  be  washed  with  a  I  in  2000  sublimate  solution. 
If  there  be  much  inflammation,  it  will  be  well  to  put  a  layer  of  mackintosh 
outside  the  wet  cyanide  dressings,  so  as  to  keep  them  moist,  and  to 
change  the  dressing  night  and  morning.  Carbolic  lotion  should  not  be 
applied  to  the  surface  of  these  wounds,  especially  in  the  early  period, 


TREATMENT  OF   INCISED  WOUNDS  161 

because  it  injures  the  vitality  of  the  granulation-cells,  and  thus  interferes 
with  their  power  of  destroying  the  virulent  organisms  on  the  surface  ; 
moreover,  granulating  wounds  treated  with  carbolic  acid  absorb  much 
more  readily  than  when  treated  in  other  ways. 

When  the  discharge  is  foul,  iodoform  is  often  useful.  This  drug  is 
not  to  be  recommended  as  an  antiseptic  for  a  freshly  made  wound  when 
the  surgeon  is  able  to  take  ah1  the  precautions  necessary  to  prevent  the 
entrance  of  micro-organisms,  but  when  applied  to  a,  putrefying  sore 
it  does  exert  antiseptic  properties  ;  it  then  seems  to  break  up  the  toxins, 
and  in  doing  so  becomes  decomposed  itself  and  free  iodine  is  liberated. 
Hence,  by  destroying  the  products  of  the  bacteria  in  septic  wounds,  the 
drug  takes  away  their  weapons,  so  to  speak,  while  at  the  same  time  the 
iodine  liberated  inhibits  the  growth  of  the  bacteria  or  may  even  destroy 
them.  Iodoform  should  always  be  disinfected  beforehand  by  immersing 
it  in  a  i  in  20  carbolic  acid  solution  for  several  days,  straining  it  through 
sterilised  muslin,  and  then  drying  it  in  a  jar  to  which  bacteria  cannot 
gain  access. 

When  granulation  is  complete  and  the  febrile  condition  has  passed 
off,  mild  antiseptic  dressings,  such  as  antiseptic  ointments,  or  the  boric 
lint  and  protective  dressing  (see  p.  51),  may  be  employed.  The  ung. 
borici  or  ung.  eucalypti  is  the  most  suitable  ointment  to  use  ;  the 
former  should  be  of  the  full  pharmacopceial  strength  at  first,  but  when 
healing  is  commencing,  half-strength  should  be  substituted,  because  the 
full-strength  ointment  seems  to  be  too  irritating  for  the  young  epithelial 
cells,  and  prevents  the  cicatrisation  of  the  wound.  If  the  wound  be  large, 
skin-grafting  may  be  employed  in  about  a  fortnight ;  the  procedure  is 
similar  to  that  for  grafting  an  ulcer  (see  p.  52). 


TREATMENT   OF  WOUNDS  THAT   CANNOT   BE    KEPT 

ASEPTIC. 

Wounds  made  by  the  surgeon  which  not  only  involve  the  skin,  but 
communicate  with  one  of  the  mucous  canals  or  with  a  septic  cavity, 
cannot  be  kept  aseptic.  It  is  impossible,  for  example,  to  exclude 
bacteria  from  a  wound  in  the  mouth,  seeing  that  they  are  everywhere 
present  in  the  fluids  on  the  surface  of  the  mucous  membrane.  The 
problem,  therefore,  is  not  how  to  exclude  them,  but  how  to  minimise 
their  deleterious  action. 

Wounds  of  Mucous  Membranes. — In  the  first  place,  it  is 
important  that  the  manipulations  during  the  operation  should  be  gentle ; 
in  other  words,  the  vitality  of  the  tissues  must  be  interfered  with  as 
little  as  possible.  Union  by  first  intention  is  not  always  obtained  in 
wounds  involving  the  mucous  membranes,  but  is  often  highly  desirable, 
especially  in  such  operations  as  staphylorrhaphy,  etc.  In  order  to 


162  WOUNDS 

obtain  primary  union  in  these  cases  the  bleeding  must  be  arrested  com- 
pletely, and  care  must  be  taken  that  no  foreign  material  is  left  between 
the  edges  of  the  wound  ;  moreover,  the  whole  of  the  cut  surface,  and  not 
merely  the  edge  of  the  mucous  membrane,  must  be  in  accurate  and  close 
apposition.  In  wounds  of  mucous  membranes  healing  by  blood-clot 
will  not  take  place.  The  best  material  for  stitches  in  these  cases  is 
either  silkworm-gut,  or  horsehair  when  a  finer  stitch  is  wanted  ;  silk 
should  not  be  used,  as  it  is  absorbent  and  will  retain  decomposing  material. 
No  dressing  applied  to  the  wound  is  likely  to  be  of  any  real  service,  but 
it  is  well  to  wash  the  surface  of  the  mucous  membrane  frequently  with 
weak  antiseptic  solutions,  such  as  permanganate  of  potash  (two  grains  to 
the  ounce),  or  sanitas  (a  teaspoonful  to  the  tumbler  of  water).  The  more 
irritating  antiseptics,  such  as  carbolic  acid,  should  not  be  employed. 

When  the  edges  of  the  wound  have  not  been  brought  together,  and 
when,  therefore,  healing  by  granulation  must  take  place,  it  is  of  great 
importance  to  avoid  septic  decomposition  on  the  surface  of  the  wound 
during  the  first  two  or  three  days  ;  at  the  end  of  that  time,  there  is 
usually  such  a  marked  invasion  of  cells  in  the  wound  that  bacteria  find 
considerable  difficulty  in  entering.  Almost  the  only  bacteria  that  are 
able  to  penetrate  at  a  later  period  than  this  are  streptococci  or  diphtheria 
organisms.  In  order  to  keep  these  sores  aseptic  for  the  first  few  days, 
Lord  Lister  used  to  sponge  over  the  surface  of  the  wound  with  a  solution 
of  chloride  of  zinc  (forty  grains  to  the  ounce),  after  the  bleeding  had  been 
arrested.  He  regarded  it  as,  so  to  speak,  pickling  the  surface  of  the  wound 
for  a  day  or  two  after  it  had  been  made  ;  after  a  thorough  application  of 
chloride  of  zinc  to  a  cut  surface  exposed  to  the  elements  of  putrefaction, 
decomposition  certainly  does  not  seem  to  occur  so  early  as  when  the 
wound  is  left  to  nature,  and  therefore  this  method  is  one  which  may  be 
strongly  recommended.  In  these  cases  also  iodoform  is  much  used  ; 
the  cut  surface  may  be  lightly  powdered  with  iodoform  crystals  after 
having  been  sponged  with  the  chloride  of  zinc  solution.  Iodoform  must 
not  be  used  too  lavishly  for  wounds  of  the  mouth,  however,  as  the  drug 
may  be  swallowed,  and  symptoms  of  iodoform  poisoning  may  appear. 

As  soon  as  the  wound  is  granulating,  mild  antiseptic  washes,  such  as 
weak  sanitas  (about  a  teaspoonful  to  a  tumbler  of  water),  permanganate 
of  potash  (one  or  two  grains  to  the  ounce),  or  boric  acid  (ten  grains  to 
the  ounce)  may  be  used.  If  the  granulations  become  prominent,  an 
occasional  application  of  solid  nitrate  of  silver  or  sulphate  of  copper 
will  keep  them  down. 

When  the  wound  involves  both  skin  and  mucous  membrane — as,  for 
example,  a  wound  of  the  cheek — the  skin-wound  should  be  stitched  up 
accurately  with  interrupted  sutures  of  silkworm-gut,  but  the  wound  on 
the  mucous  surface  should  be  painted  over  with  chloride  of  zinc  solu- 
tion, and  only  brought  together  here  and  there  with  a  few  catgut 
sutures.  A  piece  of  gauze  wet  with  a  I  in  2000  sublimate  solution 


TREATMENT  OF  INCISED  WOUNDS  163 

should  be  laid  over  the  skin  incision  for  a  few  hours,  until  the  bleeding 
has  ceased,  when  half-strength  boric  ointment  and  boric  lint  may  be 
substituted,  or  the  wound  may  be  left  uncovered  and  a  scab  allowed 
to  form.  When  there  is  a  pocket  in  the  cellular  tissue  communicating 
with  a  mucous  surface — as,  for  example,  after  operations  upon  the 
floor  of  the  mouth  and  the  glands  in  the  neck — a  large  drainage- 
tube  must  be  inserted  at  the  lowest  point  of  the  wound,  so  as  to 
prevent  accumulation.  In  three  or  four  days  this  should  be  replaced 
by  one  of  smaller  calibre,  which  should  be  cleaned  and  sterilised  by 
boiling  at  every  dressing  night  and  morning.  The  drainage-tube  can 
rarely  be  dispensed  with  before  the  third  week. 

An  antistreptoeoeeie  serum  has  been  introduced  for  use  in  cases 
of  streptococcic  infection,  which  is  the  most  serious  and  most  common 
form  of  infection  in  operations  on  mucous  membranes,  especially  about 
the  mouth.  This  serum  has  been  used  in  a  good  many  cases  as  a  pro- 
phylactic measure  before  the  operation  with  the  object  of  protecting 
the  body  for  a  time  against  streptococcic  invasion,  so  that  the  healing 
of  the  wound  shall  be  undisturbed  by  the  action  of  these  organisms. 
When  used  for  this  purpose,  20  c.c.  should  be  injected  two  days  before, 
and  10  c.c.  on  the  morning  of  the  operation.  If  there  be  not  time  for 
this,  the  injection  of  20  c.c.  the  night  before,  and  a  similar  quantity 
on  the  morning  of  the  operation,  must  suffice.  A  syringe  must  be  used 
which  can  be  disinfected  by  boiling,  and  the  best  place  for  the  injection 
is  in  the  flanks  or  the  loins  ;  the  skin  should  be  thoroughly  purified. 
The  question  of  the  value  of  this  remedy  is  still  sub  judice,  .and,  as  there 
are  probably  several  forms  of  pathogenic  streptococci,  it  is  well  not  to 
place  too  much  reliance  on  it  in  any  given  case. 

Vaccines  have  been  employed  with  advantage,  especially  when  the 
infection  runs  a  chronic  course.  The  question  of  vaccines  is  dealt  with 
in  detail  by  Dr.  Emery  (see  p.  514). 


TREATMENT   OF  INCISED  WOUNDS  INFLICTED 
ACCIDENTALLY. 

A  wound  may  not  come  under  the  notice  of  the  surgeon  until  it  has 
been  inflicted  some  hours,  and  the  problem  then  is  not  so  much  how  to 
prevent  the  entrance  of  bacteria  into  the  wound,  as  how  to  destroy  any 
that  may  have  already  entered.  The  degree  of  the  contamination  of 
such  a  wound  depends  largely  on  the  part  of  the  body  injured,  and  on 
the  weapon  with  which  the  wound  has  been  inflicted. 

In  wounds  of  the  scalp  there  is  certain  to  be  considerable  infection 
from  hairs  or  scurf  carried  into  the  wound  at  the  time  it  is  made  ;  and  as 
suppuration  in  scalp-wounds  is  often  very  serious,  both  from  burrowing  of 
pus  under  the  scalp,  and  also  from  the  proximity  of  the  diploe  and  the 


164  WOUNDS 

meninges,  it  is  very  important  that  these  wounds  should  be  disinfected 
thoroughly.  When  earth  or  grease  has  been  extensively  ground  into 
the  wound  also,  great  pains  must  be  taken  in  the  disinfection,  especially 
in  compound  fractures  or  wounds  of  joints.  The  treatment  of  these 
two  important  groups  of  accidental  wounds  is  dealt  with  in  connection 
with  the  affections  of  bones  and  joints.  Wounds  of  the  face,  or  of  parts 
not  covered  by  clothes  or  hair,  are  not  so  likely  to  be  seriously  infected  if 
the  wounds  be  incised ;  if  they  be  contused  or  lacerated,  however,  the 
blunt  instrument  which  inflicted  them  may  have  carried  in  a  quantity  of 
dirt,  and,  in  addition,  the  edges  of  the  wound  are  usually  bruised  and  of 
imperfect  vitality. 

Treatment. — When  the  contamination  is  trifling,  it  may  suffice 
to  wash  out  the  wound  well  with  a  i  in  20  carbolic  acid  solution,  but  in 
wounds  in  which  earth  or  dirt  is  obviously  present  the  treatment  must 
be  much  more  thorough.  No  attempt  should  be  made  to  obtain  healing 
by  first  intention  over  the  whole  of  the  wound,  and  therefore  the  increased 
temporary  irritation  of  the  tissues  by  the  strong  antiseptics  used  for 
thorough  disinfection  is  a  matter  of  no  consequence.  In  badly  soiled 
cases,  and  especially  in  compound  fractures,  it  is  best  to  give  the  patient 
an  anaesthetic,  and  then  to  scrub  the  wound  thoroughly  and  methodically 
with  a  nail-brush  and  strong  mixture  (see  p.  50),  picking  out  dirt  or 
foreign  bodies  with  forceps,  and  clipping  off  portions  of  the  tissues  into 
which  dirt  is  obviously  ground.  When  this  has  been  carried  out,  undiluted 
carbolic  acid  should  be  applied  to  the  entire  surface  of  the  wound  by 
means  of  a  swab.  In  applying  it,  the  margins  of  the  wound  in  the  skin 
should  be  avoided ,  as  it  may  be  necessary  to  stitch  them  together  after  the 
purification  has  been  effected ;  all  the  deeper  parts  should  be  brought 
well  into  contact  with  the  acid.  When  the  wound  in  the  deeper  parts 
is  larger  than  the  opening  in  the  skin,  the  latter  must  be  freely  incised, 
so  that  the  whole  extent  of  the  wound  is  exposed. 

Treatment  of  a  Scalp  Wound. — When,  however,  there  is  no  dirt,  grease, 
or  other  foreign  material  ground  into  the  wound,  and  the  soiling  of  the 
tissues  is  very  slight,  the  wound  can  be  disinfected  satisfactorily  with 
strong  mixture.  A  good  example  of  a  wound  of  this  kind  is  a  scalp-wound 
not  involving  the  skull  or  pericranium,  where  hairs  and  scurf  are  present 
in  the  wound.  We  shall  therefore  take  it  as  a  type,  and  describe  the 
treatment  in  detail. 

The  scalp  should  be  shaved  for  about  an  inch  in  all  directions  around 
the  margins  of  the  wound,  and  the  shaved  surface  and  the  hair  around 
disinfected  with  strong  mixture  as  in  disinfection  of  the  skin  elsewhere 
(see  p.  100).  After  this,  the  entire  surface  of  the  wound  is  cleansed 
thoroughly  and  methodically  with  strong  mixture,  and  any  tags  of 
injured  tissue  are  removed.  If  the  wound  be  an  incised  one,  its  edges 
may  be  approximated  accurately  by  means  of  silkworm-gut  sutures. 
Drainage  should  be  employed  in  all  cases  lest  the  above  measures  should 


TREATMENT  OF  INCISED  WOUNDS  165 

fail  to  secure  asepsis  ;  a  fairly  large  drainage-tube  should  be  inserted  at 
one  angle,  and  should  extend  into  any  recess  that  may  be  present  beneath 
the  scalp.  After  the  wound  has  been  disinfected  and  drained,  the  hair 
in  the  vicinity  should  be  impregnated  with  a  paste  made  by  mixing  the 
double  cyanide  of  mercury  and  zinc  with  i  in  20  carbolic  lotion ;  this  is 
rubbed  into  the  hair,  which  is  thus  converted  into  an  antiseptic  dressing. 

If  the  wound  be  a  lacerated  one,  and  particularly  if  it  be  inflicted  by  a 
dirty  blunt  instrument,  it  will  be  well  to  swab  it  over  with  undiluted 
carbolic  acid  before  bringing  its  edges  together,  and  it  is  not  necessary 
to  devote  any  great  care  to  their  approximation,  because  primary  union 
will  probably  only  be  partial  at  best ;  just  enough  stitches  should  be 
employed  to  keep  the  flap  in  place.  Antiseptic  dressings  are  then  applied 
(see  p.  150). 

Unless  there  be  pain  or  some  other  sign  of  sepsis,  the  wound  should  be 
dressed  in  about  four  days,  and  then  the  drainage-tube  may  be  left  out 
and  the  wound  allowed  to  close.  If,  however,  the  attempt  to  secure 
asepsis  has  failed  (as  will  be  evidenced  by  local  inflammation  and  general 
fever),  the  dressings  must  be  changed  more  frequently ;  but  in  no  case  is  it 
advisable  to  wash  out  the  wound  with  an  antiseptic  solution. 


TREATMENT  OF  WOUNDS   ALREADY   SEPTIC. 

Another  group  of  incised  wounds,  not  made  by  the  surgeon,  that 
demand  consideration  are  those  in  which  several  days  at  least  have 
elapsed  between  their  infliction  and  the  time  they  come  under  the  surgeon's 
notice.  Wounds  of  this  kind  may  be  divided  into  open  granulating 
wounds,  and  those  in  which  there  is  only  a  small  opening  at  the  surface 
and  a  deep  track  running  inwards ;  this  latter  condition  is  known  as 
sinus  or  fistula. 

Treatment.  —  Of  Open  Granulating  Wounds — Unless  these  are 
extensive,  involve  important  structures,  or  are  situated  on  parts  exposed 
to  frequent  movement,  they  generally  heal  readily,  provided  that  there 
be  free  exit  for  the  discharge,  which  is  the  first  essential  in  treatment.  If 
the  inflammation  be  only  slight,  an  antiseptic  gauze  dressing  (see  p.  150) 
may  be  used  and  changed  daily  ;  when,  however,  the  discharge  is  foul,  a 
lotion  of  peroxide  of  hydrogen  (10  vols.)  in  addition  is  useful.  \Vhen 
there  is  much  inflammation  in  the  neighbouring  parts,  and  especially 
when  the  wound  is  lacerated  or  contused,  constant  irrigation  (see  p.  32) 
may  be  employed.  When  the  wounds  are  in  important  situations,  such 
as  the  palm  of  the  hand,  or  close  to  and  involving  tendon  sheaths,  bones, 
and  the  like,  it  is  advisable  in  addition  to  make  an  attempt  to  obtain 
thorough  and  immediate  disinfection  of  the  part.  This  can  be  done  most 
effectually  by  putting  the  patient  under  a  general  anaesthetic,  scraping 
all  the  granulation-tissue  from  the  surface  of  the  wound  with  a  flushing 


166  WOUNDS 

spoon  (see  Fig.  52),  and  sponging  it  over  with  undiluted  carbolic  acid, 
which  is  afterwards  washed  away  with  a  i  in  2000  solution  of  perchloride 
of  mercury.  lodoform  may  then  be  sprinkled  over  the  wound  and  gauze 
dressings  applied.  When  the  wound  is  superficial  and  freely  exposed,  this 
will  generally  secure  its  disinfection.  If  there  be  any  objection  to  the 
administration  of  an  anaesthetic,  and  if  the  wound  be  small,  a  similar 
result  may  be  obtained  by  packing  it  with  lint  or  gauze  soaked  in  strong 
carbolic  oil  (i  in  5)  and  applied  to  the  wound  without  being  wrung  out ; 
this  is  changed  night  and  morning,  and  the  surrounding  skin  is  washed 
with  a  i  in  20  carbolic  acid  solution.  The  strong  carbolic  oil  is  not  an 
actual  caustic,  but  it  prevents  healing  ;  it  should  be  discontinued  as  soon 
as  the  wound  has  assumed  a  healthy  appearance,  and  strong  boric  oint- 
ment substituted  until  healing  commences  at  the  edge,  when  the  half- 
strength  ointment  should  take  its  place. 

When  Septic  Sinuses  are  present. — When  septic  sinuses  are 
present  within  the  area  of  operation — as,  for  example,  in  sequestrotomy — 
they  should  be  thoroughly  scraped  with  a  sharp  spoon  and  swabbed  with 
undiluted  carbolic  acid  before  the  operation  is  begun,  so  as  to  minimise 
the  risk  of  infecting  the  wound  that  the  surgeon  makes  during  the  course 
of  his  operation.  After  the  operation  has  been  completed,  the  septic 
cavity  should  be  scraped  again,  and  undiluted  carbolic  acid  applied,  after 
which  the  walls  of  the  sinuses  should  be  cut  away  as  completely  as 
possible.  In  this  way,  an  aseptic  wound  will  be  obtained  in  a  consider- 
able number  of  cases.  When  the  latter  is  small  or  superficial,  one  or 
more  large  drainage-tubes  should  be  inserted  into  the  most  dependent 
parts  of  the  wound,  the  skin-edges  brought  together  with  silkworm-gut, 
antiseptic  dressings  applied,  and  the  wound  treated  as  if  it  were  one 
made  through  unbroken  skin.  Should  the  attempt  to  purify  the  wound 
fail,  the  best  dressing  is  boric  lint. 

When,  however,  the  cavity  in  the  deeper  parts  is  large — as  after  opera- 
tions for  necrosis  of  the  tibia  or  femur — it  is  best  to  pack  the  wound  with 
cyanide  gauze,  without  attempting  to  bring  its  edges  together.  Unless 
this  be  done,  the  opening  in  the  skin  is  likely  to  close  so  rapidly  that  the 
discharge  from  the  deeper  parts  cannot  escape  freely,  and  healing  does 
not  occur  ;  moreover,  the  irritation  of  the  gauze  leads  to  more  rapid 
growth  of  granulations,  which  thus  fill  up  the  wound.  The  external 
gauze  dressing  should  be  changed  on  the  day  following  the  operation, 
and  subsequently  as  often  as  the  amount  of  discharge  present  may 
demand.  The  packing,  however,  should  not  be  removed  until  it  becomes 
loose ;  it  should  be  gently  pulled  upon  at  each  dressing  and  any  loose 
portions  cut  away.  After  the  loose  portion  has  been  cut  off,  fresh  gauze 
should  be  laid  on  the  remaining  packing  so  as  to  fill  up  the  cavity.  When 
the  wound  remains  aseptic  it  may  be  two  or  three  weeks  before  all  of  it 
can  be  removed.  Should  the  wound  become  septic,  the  packing  comes 
away  readily,  and  should  then  be  renewed  daily  until  the  cavity  has 


TREATMENT  OF  INCISED  WOUNDS  167 

become  almost  obliterated.  When  the  granulations  are  near  the  surface, 
the  packing  should  be  given  up,  and  weak  boric  ointment  substituted. 
The  opening  in  the  skin  has  a  constant  tendency  to  close  and  leave  a 
narrow  sinus  leading  into  a  comparatively  large  cavity.  When  the 
cavity  is  of  such  a  size  or  in  such  a  situation  that  it  is  evident  that  a  long 
time  must  elapse  before  it  can  fill  up,  it  is  a  good  plan  to  remove  freely 
the  skin  around  the  margin  of  the  opening  at  the  time  of  the  operation  ; 
any  overhanging  portion  must  always  be  cut  away,  as  it  would  only 
become  inverted  and  delay  healing.  Inversion  of  the  edges  of  the  skin 
sometimes  occurs  during  healing,  and  the  inverted  portion  may  have  to 
be  excised. 


CHAPTER    VIII. 

PUNCTURED,    CONTUSED,     LACERATED,    AND    POISONED 
WOUNDS;  BURNS,    SCALDS,   AND    FROSTBITES. 

PUNCTURED   WOUNDS. 

Characters. — A  punctured  wound  is  one  made  by  a  narrow  instrument 
so  that  its  superficial  area  is  small  in  proportion  to  its  depth  ;  there 
is  generally  a  comparatively  small  opening  in  the  skin  leading  into  a  large 
irregular  wound  in  the  deeper  parts.  The  peculiar  features  of  the 
punctured  wound  are  due  to  the  elasticity  and  contractility  of  the  injured 
parts  ;  the  elasticity  of  the  skin  tends  to  diminish  the  opening  in  it  and, 
on  the  other  hand,  the  contractility  of  the  muscles  beneath  tends  to 
increase  the  size  of  the  wound  in  them. 

Results. — The  results  of  punctured  wounds  depend  largely  on 
the  particular  structures  injured.  When  no  important  structure  has 
been  wounded,  the  pain  is  usually  slight  and  the  hsemorrhage  trifling.  If, 
however,  an  artery  be  punctured,  profuse  bleeding  results ;  this  is  the 
usual  way  in  which  a  false  aneurysm  is  produced.  In  punctured  wounds 
of  the  abdominal  wall,  the  instrument  may  penetrate  the  abdominal  cavity 
and  injure  one  of  the  viscera,  and  special  symptoms  will  then  occur,  the 
characters  and  treatment  of  which  are  considered  under  affections  of 
the  particular  organ  in  question.  Further,  if  the  instrument  which 
caused  the  puncture  pass  through  clothing,  or  if  the  puncture  be  in  a 
hairy  part,  infective  material  is  likely  to  be  carried  into  the  soft  parts, 
and  a  septic  wound  may  be  produced. 

Treatment. — In  all  punctured  wounds  it  is  advisable  to  enlarge 
the  aperture  in  the  skin  sufficiently  to  give  thorough  access  to  the  deeper 
parts,  which  should  be  cleaned  out,  the  blood-clots  removed,  and  the 
haemorrhage  arrested.  The  wound  should  then  be  washed  out  with  a 
i  in  20  carbolic  acid  solution,  any  divided  muscle  stitched  together, 
and  any  other  important  injury  to  the  deeper  parts  (e.g.  division  of  nerves) 
repaired.  When  this  has  been  done,  the  incision  which  the  surgeon  has 

168 


CONTUSIONS  AND  CONTUSED  WOUNDS  169 

made  in  order  to  gain  proper  access  to  the  wound  should  be  stitched  up, 
and  a  small  drainage-tube  inserted  at  the  seat  of  puncture.  The  puncture 
would  seldom  heal  by  first  intention  if  the  edges  were  brought  together 
throughout,  and  therefore  it  is  well  to  leave  an  opening  in  case  sepsis 
should  occur,  as  it  is  impossible  to  be  certain  that  all  septic  material  has 
been  destroyed. 

CONTUSIONS  AND  CONTUSED  WOUNDS. 

A  Contusion  is  a  severe  bruising  of  the  tissues  unaccompanied  by 
rupture  of  the  skin.  The  parts  subjected  to  the  bruising  are  more  or  less 
torn,  and  haemorrhage  occurs  into  them,  so  that  if  a  contused  area  be 
opened  up,  it  is  found  to  be  partly  torn  and  partly  infiltrated  with  blood- 
clot. 

When  the  skin  is  torn  at  the  same  time,  a  contused  wound  is  pro- 
duced, and  this  is  characterised  by  irregularity  of  the  rent  in  the  skin  and 
raggedness  of  the  edges,  which  are  much  bruised  and  infiltrated  with 
blood ;  the  deeper  parts  of  the  wound  and  the  parts  around  are  also 
bruised  and  bloody. 

Causes. — Contused  wounds  are  caused  by  crushes,  run-over  accidents, 
bites,  gunshot  injuries,  and  the  like.  As  a  rule  there  is  not  much 
bleeding,  the  vessels  being  torn  and  blocked ;  there  is  often  great  pain,  and 
the  healing  of  the  wound  is  always  slow.  Should  septic  infection  occur, 
there  will  be  suppuration  and  sloughing  of  portions  of  the  contused 
tissues ;  if  the  wound  remain  aseptic,  healing  of  the  deeper  parts  takes 
place  by  blood-clot,  and  this  is  naturally  a  prolonged  process. 

Treatment. — In  the  case  of  a  simple  contusion,  the  first  object  is  to 
prevent  any  increase  in  the  haemorrhage  that  has  already  taken  place.  If 
the  contusion  be  large,  an  icebag,  or,  if  small,  an  evaporating  lotion  (see 
p.  9)  should  be  applied  for  the  first  eight  or  ten  hours ;  the  limb  or  the 
affected  part  should  be  kept  at  rest,  upon  a  splint  if  necessary,  in  the 
elevated  position.  As  soon  as  it  is  evident  that  no  fresh  effusion  is  going 
on,  the  indication  is  to  promote  the  absorption  of  that  already  poured  out, 
and  for  this  purpose  a  firm  starch  and  cotton-wool  bandage  is  very 
efficacious  (see  p.  23).  When  the  bulk  of  the  effused  blood  has  been 
absorbed,  the  disappearance  of  the  remainder  is  greatly  facilitated  by 
careful  massage  (see  p.  23).  When  the  damage  to  the  muscle  is  severe, 
appropriate  treatment  must  be  adopted  for  this  (see  Injuries  of  Muscles). 

The  treatment  of  a  contused  wound  is  directed  primarily  towards 
securing  asepsis  ;  the  tissues  are  so  much  damaged  by  the  injury,  and  so 
much  blood  is  extravasated  into  them,  that  they  are  liable  to  become 
the  seat  of  severe  septic  inflammation,  even  though  the  organisms  that 
have  gained  access  to  the  wound  be  not  very  virulent.  As  a  first  step, 
free  access  must  be  provided  to  the  deeper  parts,  and  for  this  purpose  the 
skin  wound  must  be  enlarged,  if  necessary,  so  that  the  whole  wound  can 


170 


WOUNDS 


be  purified.  The  particular  method  employed  for  purification  will  depend 
to  a  considerable  extent  on  the  cause  producing  the  wound.  When  the 
skin  is  burst  rather  than  actually  torn  or  cut  by  an  instrument,  and  the 
case  is  seen  immediately  after  the  receipt  of  the  wound,  the  chances  are 
that  septic  organisms  have  not  penetrated  deeply.  On  the  other  hand, 
when  the  patient  has  fallen  on  stones  or  has  been  run  over  by  a  cart, 
dirt  containing  septic  organisms  has  probably  been  ground  into  the 
tissues.  In  the  milder  cases,  it  is  sufficient  to  wash  out  the  wound  with 
I  in  20  carbolic  lotion,  or,  perhaps  better,  with  strong  mixture  (see  p.  50), 
and  to  scrub  the  skin  with  a  nail-brush  and  strong  mixture.  When 
dirt  is  evidently  ground  into  the  tissues,  and  especially  when  bone 
is  injured,  it  is  best  to  clip  away  any  dirty  tissues  and  tags  of 
skin  and  muscle,  and  then  to  wash  out  the  wound  with  strong  mixture, 
and  finally  to  sponge  it  over  with  undiluted  carbolic  acid.  The 
patient  should  be  under  a  general  anaesthetic  while  the  wound  is  being 
cleansed  in  these  bad  cases.  No  stitches  should  be  employed ;  the 
wound  should  be  left  freely  open  and  a  cyanide  gauze  and  salicylic  wool 
dressing  should  be  applied ;  should  the  wound  prove  aseptic,  a  piece  of 
sterilised  protective,  sheet  rubber  or  tinfoil  should  be  applied  to  its  surface 
after  a  day  or  two,  in  order  to  prevent  the  irritation  that  this  dressing 
would  otherwise  cause.  Skin-grafting  may  be  usefully  employed  (see 
p.  54)  if  a  considerable  raw  granulating  surface  be  left. 

Should  suppuration  occur  in  these  contused  wounds,  with  much 
local  inflammation  and  a  tendency  to  sloughing,  irrigation  (see  p.  32)  is 
the  best  treatment ;  it  should  be  discontinued,  however,  when  the  wound 
becomes  covered  with  granulations,  and  either  the  gauze  dressing  or, 
still  better,  one  of  the  various  antiseptic  ointments  employed ;  the  full- 
strength  boric  ointment  should  be  used  until  it  is  evident  that  healing  has 
begun  at  the  edge,  and  then  half-strength  ointment  substituted  for  it,  so 
as  not  to  interfere  with  the  growth  of  the  young  epithelium. 

LACERATED    WOUNDS. 

In  lacerated  wounds  proper — namely,  those  caused  by  tearing —  he 
bruising  of  the  deeper  tissues  is  not  nearly  so  marked  as  in  wounds 
inflicted  by  a  direct  blow  with  a  blunt  instrument.  The  wound  is  usually 
comparatively  superficial  except  when  a  limb  is  torn  off.  The  soft  parts 
are  much  torn,  and  there  are  shreds  of  muscle  and  fascia  which  are  more 
or  less  completely  deprived  of  blood-supply  and  will  slough  should  the 
wound  become  septic  ;  in  fact,  they  will  probably  do  so  in  any  case.  The 
wound  is  usually  much  soiled  with  dirt  or  grease,  especially  in  machinery 
accidents.  These  wounds  are  inflicted  by  a  blunt  instrument,  which 
tears  the  tissues  rather  than  contuses  them  ;  the  most  typical  example 
of  this  is  in  machinery  accidents,  where  a  toothed  instrument  catches  the 
skin  and  tears  it  off  for  a  considerable  distance.  Lacerated  wounds  are 


LACERATED  WOUNDS  171 

always  to  some  extent  contused  wounds,  and  a  contused  wound  may 
also  be  a  lacerated  one. 

Treatment. — The  patient  should  be  put  under  a  general  anaesthetic, 
all  tags  clipped  away,  and  the  skin  and  the  soft  parts  thoroughly  scrubbed 
with  a  nail-brush  and  strong  mixture,  or  even  sponged  with  undiluted 
carbolic  acid  should  there  be  marked  soiling  of  the  wound.  It  is  useless 
to  stitch  the  torn  skin  together ;  at  most  one  or  two  stitches  should  be 
inserted  in  order  to  keep  the  flaps  somewhat  in  position.  Tension  must 
be  avoided;  it  would  certainly  lead  to  sloughing  of  the  flaps,  as  their 
vitality  is  already  much  interfered  with.  Gauze  dressings  should  be 
used  at  first  ;  should  suppuration  and  much  local  disturbance  occur, 
recourse  must  be  had  to  irrigation  with  weak  Condy's  fluid,  hydrogen 
peroxide,  or  sanitas  solutions.  Many  of  these  wounds,  however,  will 
heal  by  blood-clot  if  they  be  small  and  be  rendered  aseptic  by  the  purifica- 
tion described  above  ;  at  any  rate,  the  greater  part  will  heal  in  this 
manner,  though  possibly  after  a  tune  granulation  may  occur  towards 
the  centre  of  the  wound  from  the  irritation  of  the  dressirig.  When  the 
wound  is  aseptic,  there  will  be  comparatively  little  separation  of  sloughs 
either  from  the  skin  or  from  the  deeper  parts,  the  aseptic  slough,  like  a 
blood-clot,  acting  as  a  mould  in  which  new  material  is  formed. 

When  much  skin  is  torn  off  an  extremity,  the  question  of  amputation 
arises.  When,  for  instance,  the  whole  skin  of  the  forearm  has  been  lost, 
the  wound  often  does  not  heal  at  ah1  on  account  of  its  large  size 
or,  if  it  does,  so  much  contraction  results  that  the  movements  of  the 
joints  are  permanently  interfered  with,  the  result  in  bad  cases  being 
so  unsatisfactory  that  amputation  is  often  considered  the  best  practice. 
It  is  well,  however,  to  bear  in  mind  that  many  of  these  cases  can  be  got 
to  heal  by  skin-grafting,  and  a  very  useful  limb  may  result,  so  that  the 
former  rule  of  amputating  in  all  cases  of  extensive  loss  of  skin  does  not 
apply  universally  at  the  present  tune.  In  many  cases  extensive  wounds 
can  be  induced  to  heal  without  any  marked  contraction  by  allowing  the 
wound  to  granulate,  and  then  applying  Thiersch's  skin-grafts  (see  p.  54) 
before  contraction  has  taken  place,  after  scraping  away  the  soft  granula- 
tion tissue  which  has  already  formed.  Amputation  can  always  be 
performed  later  on  should  it  be  found  that,  after  all,  the  functional  result 
is  not  satisfactory. 

Even  after  skin-grafting  has  been  employed,  efforts  must  be  made  to 
counteract  the  great  tendency  to  contraction  during  healing  by  the 
careful  application  of  splints.  For  example,  in  the  case  of  loss  of  skin 
and  fascia  at  the  bend  of  the  elbow,  the  arm  must  be  kept  extended 
upon  an  anterior  splint ;  when  the  loss  is  about  the  back  of  the  hand 
the  fingers  should  be  flexed  during  the  healing  process,  the  principle 
being  that,  if  contraction  be  likely  to  occur  in  a  certain  direction,  it  is 
best  counteracted  by  fixing  the  h'mb  on  a  splint  bent  in  the  opposite 
direction.  It  must  also  be  borne  in  mind  that  the  tendency  of  the  scar 


172  WOUNDS 

to  contract  does  not  cease  when  healing  is  complete  ;  a  young  scar  will 
go  on  contracting  for  three  or  four  months  at  least.  Hence,  when  the 
skin  over  a  joint  is  involved,  the  use  of  a  splint  must  be  continued  for 
at  least  that  length  of  time  after  the  wound  has  healed.  It  may  not 
be  advisable  for  the  patient  to  wear  the  splint  night  and  day  for  the  whole 
time,  as  a  certain  amount  of  movement  of  the  joint  must  be  allowed  in 
order  to  keep  up  its  mobility  and  the  nutrition  of  the  muscles  about  it, 
but  the  splint  should  be  constantly  used  for  two  or  three  months,  and 
then  it  may  be  worn  during  the  night  only  for  another  period  of  about 
three  months.  Massage  and  passive  movements  to  ensure  proper  mobility 
in  the  neighbouring  joints,  and  to  restore  tone  to  the  muscles,  are 
valuable  auxiliaries  in  stretching  the  scar. 


POISONED   WOUNDS. 

VARIETIES. — In  speaking  of  poisoned  wounds,  reference  is  usually 
made  only  to  those  following  post-mortem  examinations,  dissections,  or 
operations,  especially  upon  parts  containing  foul  pus.  \Ve  shall  restrict 
the  term  here  to  these  conditions.  The  most  common  variety  is  the 
post-mortem  wound,  and  there  are  three  distinct  varieties  of  infection 
which  may  arise  in  this  connection. 

Lupus  Anatomicus. — This  is  the  mildest  form  and  is  also  known 
as  the  anatomical  wart.  It  consists  of  warty  growths  which  appear 
on  the  fingers  of  pathologists  and  post-mortem  porters,  and  which  are 
really  tuberculous  in  nature.  The  soft  warts  are  often  rebellious  to 
treatment,  and  in  a  certain  number  of  cases  they  give  rise  to  disease 
elsewhere — for  example,  tuberculous  glands  in  the  axilla  or  above  the 
elbow,  infection  of  neighbouring  joints  or  sheaths  of  tendons  (tuberculous 
synovitis,  or  teno-synovitis),  lung  disease,  etc.  Hence  it  is  important 
to  recognise  and  remove  the  warts  as  soon  as  possible. 

Treatment. — The  best  treatment  is  to  excise  the  growth,  going  wide 
of  it  in  all  directions ;  the  result  is  quite  satisfactory  provided  that  the 
wart  be  small,  as  a  skin-graft  can  be  applied  to  the  raw  surface,  and 
subsequent  contraction  avoided.  Even  when  the  warty  growth  is 
extensive,  it  can  best  be  got  rid  of  in  this  way  ;  should  the  tendons  be 
exposed  in  the  dissection,  loss  of  movement  need  not  be  feared  if  the 
whole  raw  surface  be  covered  with  skin-grafts. 

Should  the  size  or  situation  of  the  diseased  area  prevent  excision,  the 
warty  material  may  be  scraped  away  with  a  sharp  spoon  under  a  general 
anaesthetic.  After  the  bleeding  has  been  arrested,  the  surface  should  be 
vigorously  rubbed  over  with  nitric  acid,  which  should  be  allowed  to  act 
for  ten  minutes,  when  a  solution  containing  half  an  ounce  of  carbonate 
of  soda  to  a  tumblerful  of  water  is  poured  over  the  sore  to  neutralise 
the  acid ;  vigorous  effervescence  occurs  from  the  formation  of  carbonic 


POISONED  WOUNDS  173 

acid,  but  this  ceases  as  soon  as  the  nitric  acid  is  neutralised.  By 
far  the  best  method  of  treating  this  disease,  however,  is  by  excision 
and  subsequent  skin-grafting.  If  an  anaesthetic  be  refused  or  be 
contra-indicated,  acid  nitrate  of  mercury  should  be  applied  instead  of 
the  nitric  acid. 

Local  Septic  Infection. — The  other  troubles  which  arise  from 
post-mortem  wounds  are  septic  infections,  either  local  or  general.  The 
results  of  local  septic  infection  vary  in  severity  from  the  formation  of  a 
small  pustule  or  abscess,  to  an  extensive  diffuse  cellulitis  spreading  from 
the  fingers  up  the  hand  and  arm  ;  the  treatment  of  these  conditions  has 
been  already  described  (see  Chap.  II.). 

General  Septic  Infection. — The  most  serious  result  of  a 
post-mortem  wound,  however,  is  acute  septicaemia.  This  is  perhaps  most 
likely  to  occur  when  a  wound  is  inflicted  accidentally  while  making 
post-mortem  examinations  on  patients  who  have  died  of  suppurative 
peritonitis  ;  here  the  organisms  in  the  pus  are  particularly  virulent.  The 
patient  soon  passes  into  the  typhoid  state,  and  may  die  in  from  thirty-six 
to  forty-eight  hours. 

Treatment. — In  this  acute  form  of  septic  poisoning  there  is  little 
hope  of  a  successful  result,  as  the  disease  is  too  rapid  for  any  satisfactory 
intervention.  The  infection  is  usually  due  to  streptococci,  and  there- 
fore a  trial  should  always  be  made  of  anti-streptococcic  serum.  About 
20  c.c.  should  be  injected  when  the  patient  is  first  seen,  and  this  should 
be  followed  by  a  further  20  c.c.  in  the  course  of  the  next  twelve  hours. 
Doses  of  at  least  10  c.c.  should  be  given  every  night  and  morning,  and 
they  should  be  continued  for  at  least  two  days  after  the  temperature 
has  fallen  to  normal.  In  some  cases  good  results  are  obtained  by  larger 
doses — e.g.  40  c.c.  In  all,  the  so-called  '  polyvalent '  serum — i.e.  that 
prepared  from  a  number  of  different  strains  of  streptococcus — should 
be  employed. 

Stimulants,  such  as  brandy  in  doses  of  an  ounce  every  two  to  four 
hours  according  to  the  gravity  of  the  case,  must  be  given,  and  as  much 
fluid  nutritious  food  (beef  essences,  egg-and-milk,  etc.)  as  possible  should 
be  administered.  Quinine  should  be  given  in  doses  of  ten  grains  every 
four  hours  for  twenty-four  or  forty-eight  hours  in  spite  of  any  symptoms 
of  cinchonism  that  may  arise.  The  wound  should  be  swabbed  out  with 
undiluted  carbolic  acid,  but  the  local  symptoms  are  usually  slight 
and  seldom  call  for  special  treatment.  This  acute  form  is  extremely 
fatal,  and  the  chance  of  the  patient's  recovery  is  small.  The  subject 
will  be  considered  again  in  connection  with  infective  diseases  of 
wounds  (see  Chap.  IX.). 


174 


WOUNDS 


BURNS  AND  SCALDS. 


CAUSES. — Burns  and  scalds  are  caused  by  contact  with  solids, 
liquids,  or  gases  at  a  high  temperature  or  by  exposure  to  strongly  actinic 
light,  X-rays,  electrical  discharges,  or  radiant  heat.  Radiant  heat  only 
causes  superficial  burns,  such  as  blisters  and  erythematous  conditions 
of  the  skin.  Liquids  below  212°  F.  cause  erythema,  but  at  or  above  that 
point  they  produce  extensive  burns,  especially  if  the  liquid  has  fallen 
upon  the  clothes,  because  then  it  remains  in  contact  with  the  skin 
for  some  considerable  tune  before  the  patient  can  divest  himself  of  his 
clothing.  Caustic  liquids  cause  extensive  sloughs.  Red-hot  or  white-hot 
solids  cause  deep  and  limited  lesions ;  fused  metals  are  extremely  rapid 
in  their  action  and  char  the  parts  completely. 

X-rays,  when  applied  for  a  prolonged  period,  produce  symptoms 
resembling  an  acute  burn,  which,  however,  do  not  develop  for  a  week 
or  a  fortnight  after  the  exposure.  The  skin  then  rapidly  becomes 
red,  cedematous,  blistered,  and  extremely  painful.  Under  appropriate 
treatment  this  subsides  and  leaves  no  ill  results  beyond  a  temporary 
or  permanent  epilation.  Repeated  small  exposures  to  X-rays  produce 
an  entirely  different  tram  of  phenomena.  The  skin  becomes  glossy 
and  atrophic,  the  nails  dry,  brittle,  and  cracked,  while  teleangiectases 
and  warty  growths  appear  over  the  affected  area  ;  in  severe  cases  there 
may  be  extensive  sloughing  and  necrosis  necessitating  amputation,  and 
in  some  cases  epithelioma  of  the  skin  has  been  produced.  When  the 
patient  has  been  exposed  to  the  passage  of  a  high  voltage  current, 
especially  if  its  action  has  been  prolonged,  electric  burns  are  produced 
which  are  generally  complicated  by  ordinary  burns  produced  by  ignition  of 
the  clothes.  The  affected  skin  is  red  and  cedematous,  resembling  the  con- 
dition met  with  in  X-ray  burns,  but  the  symptoms  come  on  immediately. 
In  electric  wire-men  curious  appearances  may  be  produced  by  the  volatili- 
sation of  fuses,  especially  when  these  are  of  copper,  the  patient's  hand 
being  coated  with  a  thin  layer  of  the  metal  as  if  it  were  part  of  a  bronze 
statue.  With  low-voltage  currents  serious  burns  may  result ;  for 
example,  if  a  naked  wire  be  allowed  to  lie  in  contact  with  the  skin  for 
a  few  minutes  in  the  operation  of  electrolysis  a  white,  apparently  dead, 
area  is  produced  at  the  point  of  contact ;  part  of  this  recovers,  but  much 
of  it  will  necrose.  Radium  gives  rise  to  a  burn  of  varying  depth, 
which  is  painful  and  slow  to  heal. 

SYMPTOMS. — The  local  phenomena  of  burns  are  usually  de- 
scribed under  six  headings  or  degrees  as  originally  proposed  by  Dupuytren. 
The  first  degree  is  caused  by  the  transient  action  of  a  flame,  or  by  a 
body  below  212°  F.,  and  is  marked  by  redness  of  the  skin,  followed  by 
some  swelling  and  pain,  and  subsequently  by  desquamation.  The 
second  degree  is  caused  by  a  more  prolonged  action  of  a  flame,  by  boiling 


BURNS  AND  SCALDS  175 

water,  or  by  solids  at  212°  F. ;  and  in  this  case  the  Malpighian  layer  of 
the  skin  is  disorganised,  and  inflammation,  as  shown  by  erythema  and 
the  formation  of  bullae,  follows.  The  third  degree  is  reached  when  one 
of  the  foregoing  causes  has  acted  for  a  longer  period,  or  when  the  burn 
is  caused  by  red-hot  metal,  boiling  salt  water,  or  oil.  Here  there  is 
destruction  of  the  epidermis,  the  Malpighian  layer,  and  the  papillae  of 
the  skin,  the  result  being  that  there  is  erythema,  the  formation  of  bullae 
and  superficial  dry  eschars  ;  the  slough  separates  in  about  a  week.  In 
the  fourth  degree  the  whole  thickness  of  the  skin  and  part  of  the  sub- 
cutaneous tissue  are  destroyed ;  there  is  a  black  eschar  with  a  white 
circle  around  it,  and  a  zone  of  redness  beyond  that.  There  is  less  pain 
in  this  form  of  burn,  but  the  healing  is  slow.  In  the  fifth  degree,  not 
only  the  skin,  but  the  subcutaneous  tissue  and  portions  of  the  muscles 
are  completely  destroyed ;  it  is  caused  by  the  long-continued  action  of 
flame  or  red-hot  metals,  or  chemical  substances  such  as  arsenious  paste, 
caustic  potash,  etc. ;  a  dry  slough  is  formed,  around  which  are  seen  the 
various  minor  degrees  of  burns,  from  sloughing  of  part  of  the  skin  near 
the  eschar  to  simple  erythema  at  a  distance.  In  this  form  of  burn  joints 
are  frequently  opened,  especially  as  the  slough  separates,  and  conse- 
quently very  serious  results  may  ensue.  The  sixth  degree  of  burn  is 
that  in  which  all  the  tissues  of  the  limb  are  charred,  and  there  is 
complete  destruction  of  the  part  subjected  to  the  heat. 

A  later  phenomenon  in  burns  is  the  occurrence  of  a  certain  amount 
of  inflammation  around  the  burnt  area,  due  directly  to  the  action  of  the 
heat ;  besides  this,  there  may  be  septic  infection  with  severe  local  and 
general  results  if  the  parts  have  not  been  rendered  aseptic.  Later  still 
there  is  the  separation  of  the  slough,  granulation,  and  healing. 

The  eonstitutional  phenomena  are  divided  into  three  stages,  which 
need  only  be  alluded  to.  The  first  stage  lasts  for  forty-eight  hours,  and 
is  marked  by  congestion  of  the  parts  in  the  neighbourhood  of  the  burn, 
and  great  pain ;  besides  this,  there  may  be  congestions  of  internal 
organs.  Thus,  for  example,  when  the  burn  is  situated  over  the  thorax, 
the  pleura  or  the  lungs  may  become  congested ;  when  it  is  over  the  skull, 
the  meninges  may  be  similarly  affected,  and  so  on.  During  this  stage 
also  there  are  other  serious  dangers — for  instance,  shock,  delirium,  con- 
vulsions, asphyxia  from  carbonic  acid  or  carbonic  oxide,  or  death  with 
symptoms  of  poisoning  attributed  to  absorption  of  the  partly  broken-up 
products  of  the  burnt  tissues.  The  second  stage  of  burns  lasts  from  the 
second  to  the  sixth  or  eighth  day,  and  is  termed  the  inflammatory  period  ; 
this  is  marked  by  inflammation  of  the  part,  with  sloughing  of  the  dead 
tissues,  and  a  tendency  also  to  inflammation  of  internal  organs ;  for 
example,  a  burn  over  the  head  may  be  accompanied  by  inflammation 
of  the  brain,  a  burn  over  the  thorax  by  inflammation  of  the  pleura  or 
the  lungs.  It  is  during  this  stage  also  that  a  peculiar  phenomenon  fre- 
quently noticed  in  burns — namely,  inflammation  and,  in  some  cases, 


176  WOUNDS 

ulceration  of  the  duodenum — is  observed.  This  occurs  at  the  point  where 
the  contents  of  the  bile  duct  impinge  on  the  intestinal  mucous  membrane, 
and  is  possibly  due,  as  was  suggested  by  Dr.  William  Hunter,  to  the 
excretion,  with  the  bile,  of  irritating  products  resulting  from  an  im- 
perfect carbonisation  of  the  tissues.  In  other  cases  haematuria  or  haemo- 
globinuria  occurs.  The  third  stage  begins  when  the  slough  separates,  and 
is  mainly  occupied  by  the  healing  process.  Towards  the  end  of  the 
second,  and  in  the  early  part  of  the  third  stage,  the  patient  is  liable  to 
various  general  septic  diseases  and  also  to  local  septic  troubles  due  to 
the  position  of  the  burn  ;  for  example,  when  this  is  situated  over  a  cavity 
such  as  a  joint  or  the  pleura,  either  may  be  opened  as  the  slough  separates, 
and  violent  septic  arthritis  or  pleurisy  may  follow. 

The  Causes  of  Death  after  Burns  depend  mainly  on  the  extent,  but 
partly  also  on  the  depth,  of  the  burn  and  the  region  of  the  body  affected. 
An  extensive  superficial  burn  is  more  dangerous  than  a  limited  but  deep 
one,  whilst  a  burn  over  the  head  or  the  thorax  is  far  more  serious  than 
a  more  extensive  one  on  an  extremity.  The  causes  of  death  after  burns 
are  (i)  shock,  (2)  collapse,  (3)  poisoning  from  absorption  of  partially 
broken-down  organic  products  at  the  seat  of  the  injury,  (4)  congestion  of 
various  internal  organs,  (5)  inflammation  of  these  organs,  (6)  intestinal 
ulceration,  (7)  various  septic  diseases,  particularly  erysipelas,  septicaemia 
and  pyaemia,  and  (8)  exhaustion.  In  burns  in  particular  situations  of 
course  there  are  special  dangers  ;  for  example,  in  scalds  of  the  throat 
there  is  the  danger  of  oedema  glottidis  and  death  by  suffocation.  When 
the  patient  has  been  burnt  in  an  explosion  in  a  mine  or  in  a  burning 
house  there  may  be  symptoms  due  to  asphyxia  or  carbonic-oxide 
poisoning. 

TREATMENT. — The  treatment  may  be  described  under  four  heads 
— namely,  the  treatment  of  the  first  degree,  that  of  the  second,  that  of  the 
third  and  fourth  degrees,  and,  lastly,  that  of  the  last  two  degrees.  It  is 
also  important  to  consider  both  local  and  general  treatment. 

General  Treatment. — The  general  treatment  will  depend  largely 
upon  the  extent  and  result  of  the  burn.  When  a  patient  comes  under 
observation  suffering  from  severe  shock,  the  various  measures  appropriate 
for  the  treatment  of  that  condition  (see  p.  120)  must  be  employed. 

During  the  early  stage  also,  apart  from  shock,  it  may  be  necessary  to 
counteract  carbonic-oxide  poisoning,  which  is  indicated  mainly  by  the 
presence  of  dyspnoea,  while  the  mucous  membranes  are  of  a  cherry-red 
colour  and  the  pulse  is  slow.  A  drop  of  blood  from  a  needle-puncture 
shows  marked  deviation  in  colour  from  normal  blood :  it  is  of  the  same 
bright  cherry-red  as  the  mucous  membranes.  This  condition  is  due  to 
the  carbonic  oxide  entering  into  combination  with  the  haemoglobin,  and 
preventing  the  corpuscles  from  fulfilling  their  functions  as  carriers  of 
oxygen. 

Carbonic-oxide  poisoning  must  be  treated  by  free  stimulation,  com- 


BURNS  AND  SCALDS  177 

bined  with  efforts  to  promote  the  oxygenation  of  the  blood.  Most 
benefit  will  be  obtained  from  the  inhalation  of  oxygen  ;  and  until  this  can 
be  obtained,  artificial  respiration  by  Sylvester's  method  must  be  carried 
out  if  the  breathing  shows  any  tendency  to  flag.  If  a  cylinder  of  oxygen 
can  be  obtained,  one  end  of  an  indiarubber  tube  should  be  attached  to  it 
and  the  other  to  the  mouthpiece  of  an  ordinary  Clover's  inhaler,  a  glass 
funnel,  or  a  piece  of  brown  paper  folded  into  a  cone  ;  the  oxygen  is  then 
turned  on  and  made  to  pour  over  the  patient's  nose  and  mouth.  The 
mouthpiece  should  be  removed  every  ten  minutes  or  a  quarter  of  an 
hour  for  a  minute  or  two,  but  the  inhalation  must  be  kept  up  for  twelve 
to  twenty-four  hours,  until,  in  fact,  a  sufficient  number  of  new  blood- 
corpuscles  have  been  formed  to  act  as  carriers  of  oxygen.  Transfusion 
of  blood  has  been  suggested,  but  it  seems  that  the  blood-corpuscles  thus 
introduced  do  not  retain  their  vitality  for  any  length  of  tune,  and  act 
only  very  temporarily,  if  at  all,  as  carriers  of  oxygen  to  the  tissues.  As 
a  stimulant,  caffeine  given  subcutaneously  in  doses  of  one  grain  or  more, 
with  an  equal  quantity  of  salicylate  of  soda,  and  repeated  in  three  or  four 
hours,  is  of  use  ;  brandy  will  also  be  called  for. 

If  symptoms  of  internal  congestion  or  inflammation  set  in  after  the 
patient  recovers  from  the  shock,  the  treatment  must  be  conducted 
partly  on  the  lines  indicated  for  acute  inflammation  and  partly  on  those 
appropriate  to  the  organ  affected.  During  the  stages  of  sloughing  and 
convalescence,  it  is  necessary  to  support  the  patient's  strength  by  the 
administration  of  a  nutritious  diet  and  the  use  of  stimulants  and  tonics. 
Blaud's  pill  (ten  grains  three  times  a  day)  or  tinct.  ferri  perchlor.  (ten 
to  fifteen  minims  three  times  a  day)  may  be  given  ;  quinine  (three  grains 
thrice  daily)  is  also  of  value. 

Local  Treatment. — The  local  treatment  may  be  considered  in 
connection  with  the  various  degrees  of  burn.  In  the  First  Degree  the 
erythema  which  occurs  from  radiant  heat  requires  little  treatment. 
The  chief  trouble  complained  of  is  the  sensation  of  heat  and  burning  in 
the  part,,  and  the  use  of  some  soothing  application,  such  as  cold  cream 
or  glycerine,  which  also  acts  by  protecting  the  surface  from  contact 
with  the  air,  will  often  relieve  it ;  if  not,  lead  or  lead  and  opium 
lotion  (see  p.  9)  will  be  efficacious. 

In  the  Second  Degree,  blisters  should  be  punctured  at  the  most 
dependent  spot,  and  their  contents  let  out.  The  epidermis  should 
not  be  clipped  away,  and  the  incision  should  be  just  large  enough  to 
allow  the  fluid  to  escape  ;  if  the  blister  be  opened  freely  the  epi- 
dermis is  apt  to  peel  off,  exposing  the  papillary  layer  of  the  skin, 
causing  a  good  deal  of  pain,  and  retarding  the  healing.  When  the 
injury  has  not  gone  beyond  the  formation  of  blisters,  it  is  unneces- 
sary to  use  antiseptic  lotions,  because  the  denudation  of  the  papillary 
layer  does  not  entail  any  serious  risk  of  sepsis  ;  it  is  best  to  apply  an 
antiseptic  ointment  over  the  blisters  after  they  have  been  pricked. 


178  WOUNDS 

Eucalyptus  ointment  is  an  excellent  application,  but  half-strength  boric 
ointment  also  acts  well. 

In  the  Third  and  Fourth  Degrees,  when  there  is  partial  or  entire  de- 
struction of  the  whole  thickness  of  the  skin  or  of  the  deeper  tissues,  great 
care  must  be  taken  to  keep  the  parts  aseptic,  because  the  patient's 
greatest  risks  are  connected  with  sepsis  after  recovery  from  the  shock  and 
for  the  first  week  or  two  afterwards.  How  best  to  secure  asepsis  is  a 
question  of  considerable  difficulty,  for  it  must  be  remembered  that  burnt 
parts  absorb  fluids  with  extraordinary  rapidity,  and  this  is  especially  the 
case  with  regard  to  carbolic  acid.  Hence,  if  this  drug  be  freely  used  as  a 
disinfectant  in  burns,  grave  symptoms  of  carbolic  poisoning,  possibly 
ending  in  the  death  of  the  patient,  may  result.  Therefore  the  strong 
mixture  should  not  be  used  for  the  wound,  and  reliance  must  be  placed 
on  i  in  1000  sublimate  solution.  The  undamaged  skin  around  the  burnt 
area  may  be  safely  cleansed  with  strong  mixture. 

Since  the  heat  itself  has  disinfected  the  part,  it  is  not  necessary  to 
employ  disinfectants  with  the  thoroughness  required  in  operations,  should 
the  burnt  area  have  escaped  subsequent  soiling,  as  may  be  the  case 
when  the  patient  is  seen  soon  after  the  accident.  Absence  of  infection  may 
be  expected  when  the  burnt  part  has  not  been  covered  with  clothes  ;  when, 
however,  clothes  have  been  pulled  over  the  part  in  removing  them,  great 
care  must  be  employed  in  disinfection.  As  the  patient  is  suffering  from 
shock  and  as  the  manipulations  necessary  for  disinfection  are  very  painful, 
additional  shock  will  be  avoided  if  a  general  anaesthetic  be  administered. 
Therefore  it  will  often  be  better  to  apply  some  simple  dressing  such  as 
ung.  eucalypti  in  the  first  instance,  and  to  administer  a  full  dose  of 
morphine,  and  so  to  allow  the  patient  to  rally  from  the  shock.  He  is 
then  put  under  an  anaesthetic,  the  skin  around  is  purified  carefully  with 
strong  mixture,  and  then  it  and  the  burnt  area  are  washed  thoroughly 
with  a  i  in  1000  sublimate  solution,  which  is  subsequently  removed  by 
douching  with  sterilised  saline  solution. 

The  best  dressing  is  cyanide  gauze  rinsed  out  in  a  i  in  8000  sublimate 
solution,  and  salicylic  wool.  The  dressing  should  be  left  undisturbed 
for  two  or  three  days  if  the  temperature  remain  normal  and  the  patient 
be  comfortable  ;  indeed,  should  there  be  no  evidence  of  sepsis  after  two 
or  three  days,  the  dressings  may  be  left  on  for  a  week  or  even 
longer,  any  scabs  which  form  being  soaked  off  at  each  dressing.  The 
advantage  of  this  dressing  is  that  it  keeps  the  part  aseptic  and  also 
allows  the  discharge  to  dry  on  the  surface ;  a  reference  to  Chap.  IV.  will 
show  that  one  of  the  most  important  points  in  the  treatment  of  gangrene 
is  to  promote  drying  of  the  part.  When  the  slough  begins  to  separate 
(sometimes  it  does  not  do  so,  but  becomes  organised  in  the  same  way  as 
blood-clot)  and  the  parts  around  are  granulating  well,  eucalyptus  or  boric 
ointment  may  be  substituted.  When  the  slough  has  separated,  the  wound 
must  be  treated  as  a  healing  ulcer  (see  p.  51),  and,  if  it  be  of  any  size,  the 


BURNS  AND  SCALDS  179 

sooner  it  is  skin-grafted  the  better  (see  p.  54).     When  the  slough  is 
unduly  slow  in  separating  boric  fomentations  will  hasten  the  process. 

Picric  acid  is  much  used  for  superficial  burns,  as  it  is  said  to  allay  the 
intense  pain  effectually.  It  may  be  employed  either  as  a  saturated 
watery  solution,  painted  upon  the  burnt  area  with  a  camel's-hair  brush 
or  applied  on  butter-muslin,  or  as  an  ointment  containing  one  drachm 
of  the  acid  in  an  ounce  of  vaseline.  The  drug  is  not  without  its  dangers, 
as  toxic  symptoms — e.g.  a  rash,  pyrexia,  and  greenish-red  urine — have 
followed  its  use.  The  acid  coagulates  the  albuminous  fluid  oozing  from 
the  sore,  and  forms  a  protective  layer  over  the  exposed  nerve-endings 
in  the  skin.  The  application  should  be  made  once  or  twice  daily, 
according  to  the  size  of  the  burn  and  the  amount  of  discharge  from  it. 
We  have  found  it  useful  in  superficial  burns ;  for  the  more  severe  ones 
we  prefer  the  method  just  described. 

It  is  necessary  to  warn  the  practitioner  against  certain  commonly  re- 
commended applications  for  burns.  Carron  oil  (a  mixture  of  linseed  oil 
and  lime  water),  for  example,  is  a  filthy  application;  poultices  or  water 
dressings  and  dusting  with  flour  are  equally  bad.  The  wound  must  be 
treated  aseptically  as  far  as  possible,  as  sepsis  is  the  primary  cause  of 
death  in  a  large  number  of  deep  burns. 

Should  the  case  come  under  observation  with  a  foul  sloughing  wound, 
or  should  the  attempt  at  disinfection  fail,  and  the  wound  become  septic, 
the  best  method  of  treatment  probably  is  the  water  bath.  If  the  trunk 
be  affected  and  the  burn  be  large,  very  painful,  or  accompanied  by  con- 
stitutional disturbance,  the  patient  is  placed  in  a  bath,  the  water  (at  a 
temperature  of  100°  F.)  containing  a  small  quantity  of  an  antiseptic,  such 
as  Condy's  fluid  or  sanitas,  and  being  changed  every  three  or  four  hours. 
The  patient  should  be  taken  out  of  the  bath  at  night,  and  a  wet  boric  lint 
dressing  applied  ;  this  consists  of  boric  lint  boiled  in  a  saturated  solution 
of  boric  acid  and  applied  warm  and  wet ;  outside  this  is  placed  a  larger 
piece  of  sterilised  jaconet  or  gutta-percha  tissue.  Next  morning  the 
patient  is  again  placed  in  the  water  bath,  and  kept  in  till  evening,  and 
this  is  continued  until  the  sloughs  have  separated  and  the  inflammation 
has  subsided.  Then  boric  dressings,  antiseptic  ointments  or  protective 
and  boric  lint,  applied  as  for  healing  ulcers  (see  p.  51),  should  be  sub- 
stituted. When  the  extremities  are  affected,  special  baths  (see  p.  34) 
will  be  required. 

If  the  burn  be  of  any  size,  skin-grafting  should  be  employed  (see  p.  54) 
as  soon  as  the  sloughs  have  separated  and  the  wound  has  begun  to 
granulate  ;  this  is  especially  necessary  in  burns,  because  the  sores  result- 
ing from  them  have  a  peculiar  tendency  to  contract.  Sores  left  by  burns 
heal  much  more  slowly  than  wounds  made  by  the  knife,  probably  because 
the  heat  not  only  destroys  the  vitality  of  the  part  immediately  acted 
upon,  but  also  impairs  that  of  the  tissues  around,  so  that  in  the 
early  stages  the  vital  processes  in  them  are  not  so  active  as  usual. 


i8o  WOUNDS 

Therefore  there   is  more  granulation  tissue  formed,  and  greater  subse- 
quent contraction. 

When  the  slough  is  situated  over  a  joint  or  a  serous  cavity,  and  there 
is  reason  to  fear  that  either  may  be  opened  when  the  slough  separates, 
special  care  must  be  taken  in  the  antiseptic  management  of  the  case, 
because,  should  the  part  become  septic,  there  may  be  acute  suppuration 
of  the  articular  or  the  serous  cavity. 

In  the  Fifth  and  Sixth  Degrees  the  treatment  is  only  of  importance 
when  the  burn  affects  the  extremities ;  if  it  be  situated  elsewhere,  the 
patient  usually  dies  at  once.  Should  a  burn  of  these  degrees  occur  upon 
the  skull  or  part  of  the  trunk,  however,  and  should  the  patient  survive, 
the  aim  of  the  surgeon  must  be  to  render  and  keep  the  part  aseptic,  to 
support  the  patient's  strength,  and  to  wait  until  the  slough  separates  ; 
then,  if  no  vital  part  be  involved,  the  defect  will  be  gradually  filled  up  with 
granulations,  and  a  time  will  come  when  skin-grafting  can  be  employed. 
In  the  extremities,  however,  the  question  of  primary  amputation  arises, 
when  the  tissues  down  to  and  including  the  bone  are  completely  charred, 
or  when  only  the  fifth  degree  is  reached,  and  the  tissues  are  destroyed  over 
a  large  area.  This  question  must  be  answered  in  the  affirmative  when 
the  extremity  is  hopelessly  destroyed  ;  the  only  points  for  discussion  are 
as  to  when  and  where  the  amputation  should  be  performed.  As  a  rule 
it  is  best  to  wait  until  the  shock  has  passed  off,  for  if  amputation  be 
performed  before  this,  as  is  frequently  the  case,  the  shock  is  apt  to  be 
much  increased,  and  to  bring  about  a  fatal  result.  In  the  majority  of 
cases  it  is  quite  safe  to  wait  for  from  twelve  to  twenty-four  hours,  if  the 
part  be  roughly  disinfected  and  wrapped  up  in  an  antiseptic  dressing ; 
when  the  shock  has  been  recovered  from,  at  any  rate  partly,  amputation 
may  be  proceeded  with,  taking  care  to  employ  all  the  measures  calculated 
to  prevent  or  minimise  shock  (see  p.  118).  Spinal  analgesia  here  finds 
one  of  its  most  useful  applications.  In  determining  the  level  at  which 
to  amputate  it  must  be  remembered  that  it  is  not  necessary  to  go  far 
above  the  actually  charred  tissue ;  there  is  certainly  no  need  to  go  above 
the  region  of  the  erythema.  If  the  part  be  kept  aseptic  this  congestion 
will  subside  without  leading  to  any  trouble  during  the  healing  of  the 
stump  ;  special  attention  must  be  devoted  to  the  purification  of  the  skin 
in  the  region  of  the  amputation. 


EFFECTS  OF  INTENSE  COLD. 

The  local  effects  of  intense  cold  in  some  respects  resemble  those 
of  heat.  The  parts  chiefly  affected  are  those  most  distant  from  the 
heart,  such  as  the  toes  and  the  fingers  (especially  the  great  toe  and  the 
little  finger),  the  nose  and  the  ears.  Moist  cold  is  more  likely  to  do  harm 
than  dry,  and  when  there  is  wind,  frostbite  is  much  more  likely  to  occur 


EFFECTS  OF  INTENSE  COLD  181 

than  when  the  atmosphere  is  still.  The  effect  of  cold  is  to  cause  great 
local  contraction  of  the  vessels,  so  that  the  part  at  first  becomes  livid  and 
ultimately  white.  On  the  cessation  of  the  cold,  reaction  takes  place  ;  the 
vessels  become  greatly  dilated,  and  stasis  is  apt  to  occur  and  may  end  in 
thrombosis  if  the  reaction  be  too  severe.  When  death  results  from  cold, 
the  most  common  appearance  met  with  post-mortem  is  thrombosis  of  the 
vessels  of  the  internal  organs.  Various  other  local  changes  are  described 
as  the  result  of  cold,  the  most  important  being  degeneration  or  inflamma- 
tion of  nerves  ;  these  may  possibly  have  something  to  do  with  the  peculiarly 
languid  ulcerations  which  affect  parts  that  have  been  exposed  to  severe 
cold.  The  changes  probably  result  from  thrombosis  of  the  nutrient 
vessels  of  the  nerves. 

The  clinical  effects  of  cold  may  be  divided  into  three  degrees.  The 
first  degree  corresponds  to  the  first  degree  of  burns :  it  consists  simply  of 
erythema  of  the  part,  and  is  a  reactionary  phenomenon  :  the  second  degree 
corresponds  to  the  second  degree  of  burns,  at  any  rate  to  a  great  extent ; 
and  the  third  degree,  or  frost-bite  proper,  may  be  taken  to  represent  the 
remaining  degrees  of  burns. 

Chilblains. — The  first  effect  of  cold  is  erythema.  The  skin  becomes 
of  a  wine-red  or  violet  colour,  which  disappears  on  pressure  ;  the  cutaneous 
circulation  is  slow  and  there  is  swelling  of  the  skin  and  subcutaneous 
tissues,  with  a  feeling  of  numbness  in  the  part.  In  addition  to  this 
feeling  of  numbness  there  is  much  itching  and  pricking,  if  heat  be  applied 
too  suddenly.  This  condition  generally  disappears  in  a  few  days  ;  if, 
however,  the  exposure  to  cold,  followed  by  the  application  of  heat,  be 
repeated,  it  may  lead  to  the  condition  known  as  chilblain  which,  if  not 
properly  treated,  may  become  cracked  and  ulcerated. 

Ulcers. — The  second  degree  of  cold  leads  to  the  formation  of  bullae 
containing  clear  or  bloody  fluid,  and  these  may  be  followed  rapidly  by 
atonic  ulcers  which  show  little  tendency  to  heal ;  there  is  also  smarting 
in  the  part.  When  the  condition  is  yet  more  chronic  we  have  what  are 
practically  ulcerating  chilblains,  the  skin  being  swollen,  cedematous, 
cracked,  and  marked  by  shallow  fissures  which  yield  a  yellow  or  brownish 
liquid,  very  prone  to  dry  up.  These  cracks  enlarge  and  form  obstinate 
ulcers. 

Frostbite. — The  third  degree  is  that  in  which  the  skin  and  a  variable 
amount  of  the  deeper  tissues  die  ;  the  skin  becomes  livid  and  mottled, 
and  numerous  large  bullae,  containing  rusty-coloured  serum,  are  formed, 
or  else  sloughing  takes  place.  If  warmth  be  applied  too  quickly,  the 
condition  results  in  severe  inflammation,  followed  by  gangrene.  The 
gangrene  spreads  slowly,  and  there  is  an  imperfect  and  temporary  line 
of  demarcation  much  the  same  as  in  the  senile  form  ;  if  opportunity  be 
afforded,  the  dead  part  dries  up,  but  the  gangrene  is  not  typically  a  dry 
one  from  the  first.  In  other  cases  the  sloughing  is  quite  superficial,  but 
the  frostbite  is  followed  by  permanent  malnutrition,  with  anaesthesia, 


182  WOUNDS 

analgesia,  or  even  atrophy  of  the  limb,  or  by  the  formation  of  perforating 
ulcers. 

TREATMENT. — Prophylactic. — The  treatment  of  the  effects  of 
cold  is  partly  prophylactic  and  partly  curative.  As  a  measure  of  pro- 
phylaxis, persons  who  must  necessarily  be  exposed  to  severe  cold  should 
take  large  quantities  of  fatty  food.  The  clothing  should  be  thick  and 
woollen,  it  should  not  be  tight-fitting,  and  the  feet  especially  should  be 
kept  warm  ;  the  body,  particularly  the  exposed  parts,  should  be  oiled 
in  order  to  prevent  evaporation,  and  when  the  patient  is  exposed  to 
intense  cold,  he  should  keep  actively  moving,  and  must  not  yield  to  the 
desire  to  rest  or  sleep,  which  is  often  very  great. 

Curative. — Of  the  First  Stage. — When  the  cold  has,  so  to  speak, 
got  hold  of  the  patient,  he  should  not  be  brought  at  once  into  a  warm 
room,  as  otherwise  the  reaction  is  likely  to  be  so  great  that  thrombosis 
of  the  vessels  occurs.  The  affected  part  should  at  first  be  rubbed  with 
snow  or  cold  water,  while,  after  a  little  time,  dry  friction  may  be  sub- 
stituted, and  then  the  heat  very  gradually  increased.  Dry  friction 
should  first  of  all  be  practised  by  the  hand,  for  which  slightly  warmed 
cloths  may  afterwards  be  substituted,  and  then  the  patient  may  be  exposed 
to  the  air  of  a  warm  room  at  a  distance  from  the  fire.  When  this  stage  has 
been  passed  and  the  erythematous  condition  has  supervened,  the  best 
applications  are  stimulant  lotions,  such  as  camphorated  alcohol,  rubbed 
into  the  part.  The  question  of  food  is  also  important.  At  first  both 
food  and  drink  should  be  cold,  and  warm  nourishment  should  be  permitted 
only  gradually. 

Treatment  of  Chilblains. — When  chilblains  are  present  and  the  skin 
is  still  unbroken,  various  applications,  in  which  flexile  collodion  is 
the  vehicle,  are  of  use.  The  following  are  the  most  valuable.  When 
there  is  great  itching,  the  irritation  can  be  much  relieved  by  the  applica- 
tion of  flexile  collodion  containing  two  per  cent,  of  cocaine.  In  painting 
this  on  a  chilblain  affecting,  say,  the  toe,  care  must  be  taken  not  to 
surround  the  base  of  the  toe  completely  with  it,  as  otherwise  the  con- 
traction which  ensues  as  it  dries  will  constrict  the  toe  and  interfere  with 
the  return  circulation.  The  collodion  should,  therefore,  only  be  painted 
on  the  main  portion  of  the  chilblain,  and  no  collodion  should  be  applied 
on  one  side  (in  the  case  of  the  great  toe,  the  outer  side).  When 
the  chilblains  are  very  tender,  turpentine  is  useful,  and  the  following 
prescription  is  very  satisfactory : 

B  Collodion  .          .          .          .          .2  oz. 

Venice  turpentine      .          .          .          .6  drachms 
Castor  oil  .....     3  drachms. 

The  turpentine  does  not  allow  the  collodion  to  dry  completely,  and  the 
stocking  is  consequently  apt  to  stick  to  the  skin  ;  it  is  well,  therefore,  to 
place  a  piece  of  boric  lint  around  the  toe  outside  the  collodion  as  soon  as 


EFFECTS  OF   INTENSE  COLD  183 

it  has  partly  dried,  and  this  can  afterwards  be  removed  with  warm 
water.  This  application  should  be  renewed  at  least  once  daily,  or  oftener 
if  the  patient  has  been  walking  about.  Glycerinum  belladonna  smeared 
freely  over  the  inflamed  part  is  also  of  value,  and  it  is  more  suit- 
able when  the  chilblain  surrounds  the  toe  entirely ;  a  piece  of  boric 
lint  is  covered  with  the  preparation  and  wrapped  round  the  toe.  Five 
per  cent,  salicylic  ointment  is  also  a  valuable  application,  while  other 
cases  seem  greatly  benefited  by  a  few  short  exposures  to  the  X-rays. 

When  the  chilblains  are  ulcerating,  the  best  application  is  a  piece  of 
lint  soaked  in  balsam  of  Peru,  and  with  some  excess  of  it  on  the  surface. 
In  changing  the  dressings,  the  chilblain  should  be  bathed  with  warm 
boric  lotion  ;  the  application  should  be  renewed  night  and  morning. 

Cod  liver  oil  (3j)  and  syrup  of  iodide  of  iron  (H\xx-xxv)  should  be  given 
internally  three  times  a  day.  Ichthyol  in  pills  of  I  to  3  gr.  thrice  daily  is 
said  to  be  valuable.  Nourishing  diet,  with  plenty  of  fatty  food,  should 
be  given,  and  when  the  chilblains  affect  the  feet  and  have  ulcerated,  the 
patient  must  either  lie  up  entirely,  or  must  refrain  from  walking.  In 
any  case  thick,  warm,  undarned  stockings,  with  stout  well-fitting  boots 
and  warm  gloves,  should  be  worn. 

Of  the  Second  Stage. — In  the  second  stage  of  cold,  stimulant 
lotions  or  balsam  of  Peru  (vide  supra)  are  the  best  applications  in  the  first 
instance.  As  the  ulceration  is  usually  of  an  atonic  form,  everything 
possible  should  be  done  to  increase  the  nutrition  of  the  limb.  Massage 
applied  to  the  whole  limb  above  the  limit  of  the  sore  will  keep  the  circu- 
lation active,  and  will  be  of  great  benefit ;  electricity  in  the  form  of 
electric  baths,  or  the  Faradic  current  applied  to  the  muscles,  and  used  in 
precisely  the  same  way  as  for  cases  of  Raynaud's  disease,  is  of  great  value 
(see  p.  77). 

When  the  sore  begins  to  heal,  half-strength  boric  ointment  may 
be  substituted  for  the  balsam  of  Peru.  The  part  should  be  elevated, 
but  it  may  not  be  necessary  to  keep  the  patient  in  bed,  rest  on  a  sofa 
often  being  sufficient ;  this  point,  however,  must  be  determined  by  the 
progress  of  the  ulcer.  If  it  does  not  heal,  or  if  it  shows  signs  of  spreading 
when  the  patient  is  allowed  to  remain  on  the  sofa,  rigid  confinement  to 
bed,  with  the  foot  elevated,  must  be  enforced.  Cod  liver  oil  should  be 
administered  internally,  together  with  stimulants  and  a  nutritious  diet. 

Of  the  Third  Stage  (Frostbite). — In  the  first  place,  the  part  should 
be  thawed  by  friction  with  snow  (see  p.  182),  and  then  wrapped  up 
in  cotton-wool.  If,  however,  the  frostbite  be  severe,  it  is  well  to  disinfect 
the  part  at  once,  shaving  the  skin,  scrubbing  it  with  strong  mixture, 
cleaning  the  nails,  as  already  described  for  gangrene  (see  p.  68),  and 
then  wrapping  up  the  limb  in  cyanide  gauze  and  salicylic  wool.  Im- 
mediate amputation  should  not  be  performed  ;  it  is  advisable  to  wait 
for  a  line  of  demarcation.  It  is  not  uncommon  to  find  that  the  slough 
only  involves  the  skin  and  subcutaneous  tissues,  or  even  only  the  surface 


1 84  WOUNDS 

of  the  skin,  and  a  short  delay  may  prove  that  amputation  is  not  called 
for.  In  any  case,  there  is  no  guide  to  the  proper  place  for  amputation 
until  a  line  of  demarcation  has  formed,  for  it  is  impossible  to  say  at  first 
to  what  extent  the  tissues  have  been  irretrievably  damaged.  As  soon, 
however,  as  there  is  a  clear  indication  of  the  extent  of  the  frostbite,  there 
is  no  necessity  to  wait  any  longer,  and  amputation  may  be  proceeded 
with  at  once.  In  most  cases  of  frostbite  of  the  foot,  a  Chopart's  or 
Syme's  amputation  will  suffice  ;  it  is  seldom  that  the  gangrene  reaches 
the  ankle.  If,  however,  the  surgeon  wait  too  long,  the  gangrene  is  apt 
to  spread  (as  is  the  case  with  the  senile  form),  the  weak  tissues  being 
unable  to  resist  the  inflammation  associated  with  the  separation  of  the 
dead  part.  On  the  other  hand,  if  the  amputation  be  performed  anti- 
septically,  no  further  inflammation  occurs,  and  there  is  no  gangrene  of 
the  flaps.  Thus,  by  waiting  too  long,  more  tissue  may  be  lost  than  if 
the  amputation  were  performed  as  soon  as  the  appearance  of  a  line  of 
demarcation  indicates  the  extent  of  the  original  gangrene. 

The  general  treatment  of  the  third  stage  of  frostbite  is  similar  to 
that  of  the  less  severe  forms  (see  p.  183). 


CHAPTER    IX. 
INFECTIVE  DISEASES  OF  WOUNDS. 

IN  the  preceding  chapters  we  have  laid  the  very  greatest  stress  on  the 
aseptic  management  of  the  wound,  but  no  consideration  of  the  subject 
would  be  complete  unless  reference  were  made  to  the  various  results 
which  may  ensue  either  when  these  precautions  have  not  been  taken,  or 
when  they  have  been  carried  out  inefficiently. 

It  must  be  remembered,  in  connection  with  the  various  septic  diseases 
that  may  attack  wounds,  that  although  such  affections  as  septic  intoxica- 
tion, traumatic  fever,  septicaemia,  and  pyaemia  are  described  as  different 
conditions  possessing  clearly  differentiated  symptoms  and  a  definite  patho- 
logy, yet  in  actual  practice  there  are  numerous  gradations  between  them, 
so  that  it  is  often  impossible  to  say  where  one  ends  and  the  other  begins. 
Thus  a  condition  of  septic  intoxication  readily  passes  into  one  of  traumatic 
fever,  which  in  its  turn  may  end  in  one  of  the  forms  of  septicaemia  or  of 
pyaemia.  Even  septicaemia  and  pyaemia,  which  are  the  two  members 
of  the  group  that  differ  most  widely,  may  both  occur  as  the  result  of  the 
septic  infection  of  the  same  wound.  Indeed,  seeing  that  in  all  probability 
the  same  organisms  are  concerned  in  most  of  these  affections,  it  is  not 
illogical  to  regard  the  latter  as  being  merely  varieties  of  the  one  funda- 
mental condition  of  septic  contamination,  the  particular  form  that  the 
affection  takes  depending  upon  a  variety  of  factors,  such  as  the  virulence 
and  concentration  of  the  infective  material,  the  distribution  of  the 
organisms,  and  the  anatomical  conditions  of  the  part  affected. 

SEPTIC  INTOXICATION. 

The  organisms  which  gain  access  to  wounds  may  be  either  sapro- 
phytes— i.e.,  those  growing  in  dead  tissues  or  in  fluids,  but  having  no 
power  of  penetrating  into  the  living  body  ;  or  parasites — i.e.  those  which 
live  and  flourish  in  the  bodies  of  animals  whose  tissues  or  fluids  furnish 
suitable  media  for  their  development ;  the  latter  group  are  usually  capable 

185 


186  WOUNDS 

also  of  saprophytic  growth.  Although  the  true  saprophytes  are  unable  to 
grow  in  living  tissues,  they  may  nevertheless  cause  serious  results  and  may 
even  bring  about  the  death  of  the  patient  whose  wounds  they  infect,  for,  as 
they  grow  in  organic  materials,  they  give  rise  to  various  poisonous  sub- 
stances, which,  if  absorbed  into  the  body,  may  cause  the  condition  known 
as  septic  intoxication.  Septic  intoxication  therefore  is  an  affection 
produced  not  by  parasitic  growth  in  the  body,  but  by  the  absorption  of 
products  of  decomposition  formed  in  the  wound.  These  products  are 
mainly  the  result  of  the  growth  of  saprophytes,  but  they  are  also  to  some 
extent  produced  by  organisms  which  can  become  parasitic  should  the 
patient  live. 

SYMPTOMS. — The  symptoms  of  septic  intoxication  are  due  to  the 
poison  which  is  absorbed  into  the  system.  The  condition  in  former 
days  was  not  recognised  as  such  and  was  often  spoken  of  as  '  secondary 
shock.'  The  affection  can  only  occur  in  large  wounds,  because  it  is  only 
in  them  that  sufficient  toxic  material  can  be  formed  to  provide  a  poisonous 
dose ;  for  example,  it  may  be  met  with  in  amputations  at  the  hip  joint, 
operations  upon  large  joints  such  as  the  knee,  extensive  compound 
fractures,  extensive  operations  about  the  breast  and  axilla,  many  abdo- 
minal operations,  psoas  abscess,  and  so  forth.  The  clinical  history  is 
somewhat  as  follows.  In  the  first  place,  the  operation  being  a  severe  one, 
the  patient  suffers  from  collapse,  with  depression  of  temperature,  feeble 
pulse,  etc.,  and  as  the  shock  is  recovered  from,  this  is  followed  by  reaction 
with  pyrexia.  The  temperature  usually  rises  considerably  within  twenty- 
four  hours  ;  then  it  falls  rapidly  and  the  patient  again  passes  into  a 
condition  not  unlike  that  of  shock.  He  becomes  semi-conscious,  the 
pulse  is  weak  and  fluttering,  and  the  temperature  low  ;  if  this  condition 
persist,  he  may  die.  The  affection  is  very  grave  in  those  who  have  renal 
disease,  for  whereas  the  poison  is  rapidly  excreted  by  the  healthy  kidneys, 
the  excretion  may  not  be  sufficiently  rapid  to  save  the  patient's  life  if 
they  are  diseased.  Hence  the  old  rule,  on  which  so  much  stress  was 
laid,  was  that  no  operation  should  be  undertaken  when  there  was  albumin 
in  the  urine.  Nowadays  this  does  not  apply  with  such  rigour,  since  we 
do  not  anticipate  such  a  catastrophe  as  septic  intoxication.  Milder 
conditions  of  septic  intoxication  may  also  occur,  in  which  there  is  no 
great  lowering  of  temperature  ;  in  them  the  patient  recovers  rapidly. 

TREATMENT — Local. — When  the  above  symptoms  appear,  the 
clear  indications  are  to  get  rid  of  all  decomposing  materials  from  the 
wound,  so  as  to  stop  the  absorption,  and  then  to  support  the  patient's 
strength  and  promote  the  excretion  of  the  poison  which  has  already 
entered  the  body.  Hence,  the  wound  should  at  once  be  opened  up  freely, 
the  stitches  taken  out,  and  all  decomposing  blood-clot  and  other  material 
cleared  out.  The  wound  should  then  be  thoroughly  irrigated  with 
sterilised  saline  solution  at  a  temperature  of  about  104°  F.  ;  these  hot 
lotions  act  as  a  general  stimulant  and  do  not  damage  the  tissues.  Anti- 


SEPTIC  INTOXICATION  187 

septics  such  as  carbolic  acid  should  not  be  used,  because  they  cannot 
possibly  disinfect  the  \vound,  and  they  may  be  absorbed  and  render 
the  patient's  condition  still  more  serious ;  further,  they  cause  the 
formation  of  a  layer  of  coagulated  albumen  on  the  surface  of  the 
wound,  beneath  which  the  organisms  are  protected  and  may  grow  again. 

After  the  wound  has  been  thoroughly  washed  out,  a  few  stitches  are 
again  inserted  and  one  or  more  large  drainage-tubes  introduced  to  provide 
free  escape  for  the  discharge.  The  cyanide  gauze  and  salicylic  wool  is 
probably  as  good  a  dressing  as  can  be  applied  ;  it  should  be  changed  and 
the  wound  washed  out  again  through  the  drainage-tube  in  the  course  of  a 
few  hours.  Whether  an  anaesthetic  should  be  given  for  the  purpose  of 
opening  up  and  draining  the  wound  depends  on  the  condition  of  the 
patient.  If  he  be  in  a  very  depressed  state  it  is  well  to  avoid  it,  as  the 
procedure  does  not  involve  any  great  pain,  and  the  anaesthetic  might  add 
to  the  depression. 

General  Treatment. — Stimulants  are  indicated.  Brandy  may  be 
given  either  by  the  mouth  or  by  the  rectum  ;  in  desperate  cases  it  may 
even  be  injected  subcutaneously  and  under  these  circumstances  ether  in 
ten- to  twenty-minim  doses  may  be  similarly  used ;  the  injection  should  be 
made  into  the  muscles,  for  a  slough  is  apt  to  form  afterwards  if  it  be  merely 
introduced  beneath  the  skin.  Strychnine  is  of  great  value  in  this  condition, 
a  thirtieth  of  a  grain  being  given  subcutaneously  and  repeated  hourly 
for  two  or  three  doses  ;  its  action  is  often  increased  by  the  addition  of  a 
hundredth  of  a  grain  of  digitaline  to  it.  Under  the  combined  influence 
of  these  drugs  the  pulse  becomes  much  steadier,  for  a  time  at  any  rate, 
and  the  patient's  condition  improves.  Ammonium  carbonate  (gr.  ij-iij) 
or  sal  volatile  (3ss)  may  be  given  hourly.  Everything  must  be  done  to 
keep  the  patient  alive  for  a  few  hours  until  the  poison  in  the  blood  can  be 
excreted. 

When  the  toxaemia  is  profound,  saline  infusion  is  of  the  greatest  value 
in  diluting  and  helping  the  excretion  of  toxins  and  in  keeping  up  the 
blood-pressure.  When  the  bowels  are  not  irritable,  this  is  best  given 
by  the  drop  method  described  in  speaking  of  shock  (see  p.  115).  When 
this  plan  is  not  feasible,  about  fifteen  ounces  of  the  saline  solution 
may  be  injected  into  the  axilla  (in  an  adult)  every  hour  until  the 
patient  improves  or  is  obviously  moribund. 

Vomiting  is  a  very  distressing  feature  in  some  cases,  and,  should  it 
persist,  simple  effervescing  mixtures,  such  as  effervescing  citrate  of  caffeine, 
in  teaspoonful  doses  will  often  check  it  :  a  mixture  containing  five 
minims  of  dilute  hydrocyanic  acid  with  a  drachm  of  liquor  bismuthi,  or 
fifteen  grains  of  carbonate  of  bismuth  suspended  in  mucilage,  to  the  ounce 
of  water,  is  also  often  useful.  When  recovery  is  taking  place,  the  patient 
should  be  encouraged  to  drink  large  quantities  of  fluid  so  as  to  dilute  the 
poison,  and  it  is  well  to  use  the  '  imperial  drink  '  referred  to  on  p.  15, 
which  is  also  a  diuretic.  When  convalescence  is  established,  a  liberal 


i88  WOUNDS 

diet  must  be  ordered  and  tonics  administered.  When  the  wound  has 
granulated,  further  danger  from  this  particular  form  of  septic  absorption 
disappears. 

TRAUMATIC    FEVER. 

As  long  as  the  organisms  that  have  gained  access  to  a  wound  remain 
limited  to  the  fluids  or  dead  tissues  in  it,  or  are  purely  saprophytic  in 
nature,  they  are  only  capable  of  giving  rise  to  a  condition  of  septic  intoxi- 
cation pure  and  simple.  Should  any  of  the  organisms  producing  this 
septic  intoxication  be  capable  of  parasitic  growth,  however,  and  should 
they  gain  entrance  to  the  living  tissues  of  a  wound  of  any  size,  the  con- 
dition known  as  traumatic  fever  arises.  This  is  due  partly  to  absorption 
of  the  products  of  saprophytic  growth  in  the  wound,  and  partly  also 
to  the  entrance  of  pyogenic  organisms ;  it  generally  continues  until  the 
establishment  of  granulation  and  suppuration.  When  it  occurs,  the 
reactionary  pyrexia  which  often  follows  aseptic  operations  runs  up  to 
103°  or  104°  F.  instead  of  abating,  and  then  falls  slowly  in  an  intermittent 
manner,  until  the  fourth  or  fifth  day,  when  it  falls  rapidly,  the  final 
descent  coinciding  with  the  complete  establishment  of  granulation. 
Traumatic  fever  does  not  usually  prove  fatal,  unless  it  end  in  septicaemia 
or  pyaemia  j  suppuration  always  occurs  in  the  wound,  however,  and 
attention  must  be  specially  directed  to  the  local  condition. 

TREATMENT. — As  soon  as  traumatic  fever  sets  in,  the  wound 
must  be  dressed,  and  efficient  drainage  established.  When  no  drainage  has 
been  employed,  the  wound  should  be  thoroughly  opened  up  and  large 
tubes  inserted.  When  tubes  have  been  inserted  at  the  time  of  operation, 
the  wound  should  be  washed  out  with  warm  sterilised  saline  solution, 
with  the  object  of  getting  rid  of  decomposing  clots.  This  should  be  done 
at  the  first  dressing,  but  should  not  be  repeated  ;  washing  out  a  wound 
injures  the  delicate  granulation -tissue  without  killing  the  organisms 
which,  being  of  the  ordinary  pyogenic  variety,  have  already  penetrated 
into  the  tissues.  The  injury  done  to  the  granulations  by  irrigation  of  a 
wound  may  enable  the  organisms  to  penetrate  more  freely  into  the  body 
and  set  up  septicaemia  or  pyaemia. 

The  antiseptic  dressings  should  be  changed  daily,  and  the  surgeon 
must  wait  until  he  sees  whether  the  condition  merely  ends  in  suppura- 
tion, or  whether  some  more  serious  complication  is  going  to  arise.  When 
the  case  ends  in  suppuration,  the  temperature  falls  about  the  fourth  or 
fifth  day,  and  the  patient  soon  recovers. 

The  diet  should  be  somewhat  restricted,  and  it  is  well  to  avoid  the  use 
of  stimulants,  or  at  any  rate  to  give  them  only  in  very  small  quantities 
unless  the  temperature  be  high  and  the  general  condition  bad  ;  during 
the  acute  sthenic  stage  of  inflammatory  fever  they  are  not  really  called 
for.  The  patient  should  take  plenty  of  '  imperial  drink  '  (see  p.  15),  so 


ACUTE  SEPTICEMIA  189 

as  to  keep  the  kidneys  active  ;  the  bowels  should  be  kept  open  with 
mild  saline  aperients  such  as  Seidlitz  powders  or  drachm  doses  of  sulphate 
of  magnesia  or  effervescing  sulphate  of  soda,  combined  with  enemata. 


ACUTE   SEPTICAEMIA. 

This  condition  is  much  more  serious  than  the  one  just  described. 
Like  it,  acute  septicaemia  is  also  due  to  the  pyogenic  organisms,  but 
the  exact  pathology  is  not  very  clear.  It  is  sufficient  for  our  purpose 
to  point  out  that  the  affection  is  essentially  one  of  poisoning  by  chemical 
products.  The  organisms  themselves  are  not  met  with  free  in  the  blood 
in  any  large  numbers,  and  they  probably  establish  themselves  either  in 
the  wound  or  in  some  of  the  internal  organs,  whence  they  pour  septic 
products  into  the  blood.  Although  the  condition  resembles  that  of 
septic  intoxication  in  being  due  to  chemical  poisoning,  it  differs  from  it 
both  by  being  caused  exclusively  by  parasitic  organisms,  and  by  the  fact 
that  these  latter  have  gained  a  footing  either  in  the  living  tissues  of  the 
wound  or  in  the  internal  organs.  Acute  septicaemia  follows  traumatic 
fever  when  the  latter  does  not  end  favourably. 

SYMPTOMS. — These  usually  begin  before  the  traumatic  fever 
has  subsided.  The  temperature,  which  has  begun  to  fall,  rises  again  to 
103°  or  104°  F.  and  remains  high,  but  shows  slight  morning  remissions  of 
about  a  degree.  Rigors  are  rare,  but  the  patient  feels  ill  and  at  first 
presents  all  the  signs  of  sthenic  inflammatory  fever ;  in  bad  cases  he  soon 
passes  into  the  typhoid  state.  Vomiting  is  not  uncommon,  and  some- 
times diarrhoea  is  present,  though  more  commonly  there  is  constipation. 
The  urine  frequently  contains  albumin,  the  wound  is  usually  swollen 
and  painful,  and  the  discharge  from  it  is  diminished  or  even  arrested 
completely.  The  disease  is  very  fatal ;  only  a  small  number  of  those 
attacked  recover. 

Treatment. — This  is  mainly  directed  to  the  symptoms ;  but  when 
examination  of  the  discharges  from  the  wound  shows  the  presence  of  the 
streptococcus  pyogenes,  antistreptococcic  serum  should  be  injected 
(see  p.  173).  Vaccines  are  often  employed,  but  their  use  is  not 
devoid  of  danger  (see  Appendix).  Usually,  however,  there  is  nothing 
to  be  done  but  to  employ  constitutional  treatment,  in  the  hope 
that  the  tissues  may  conquer  in  the  fight  against  the  organisms. 
A  generous  diet  should  be  given,  and  free  stimulation  will  be  necessary 
as  soon  as  the  pulse  begins  to  fail.  If  the  temperature  remains  over 
103°  F.,  tepid  sponging  or  some  of  the  other  antipyretic  measures 
recommended  on  p.  194  should  be  adopted.  Ten  grains  of  quinine 
should  be  given  every  four  hours  for  twenty-four  or  forty-eight 
hours  even  in  spite  of  symptoms  of  cinchonism.  The  object  is  to  get  a 
bactericidal  effect ;  this  can  only  be  done  by  practically  poisoning  the 


i9o  WOUNDS 

patient  with  the  drug,  which  is  then  discontinued  for  twenty-four  hours 
and  drachm  doses  of  Warburg's  tincture  every  four  hours  substituted. 
This  plan  is  sometimes  very  satisfactory.  The  bowels  and  the  kidneys 
should  be  kept  acting  freely. 

The  wound  should  always  be  opened  up  and  drained  freely,  but  at 
this  stage  there  is  no  chance  of  really  disinfecting  it  or  of  preventing  the 
entrance  of  organisms  into  the  body.  When  the  wound  is  in  one  of  the 
extremities,  amputation  has  been  done  in  a  considerable  number  of  cases ; 
but  unfortunately,  this  has  little  effect  on  the  progress  of  the  disease, 
for  in  most  cases  the  organisms  seem  to  be  established  in  the  internal 
organs,  and  the  only  result  of  amputation  is  to  lower  the  patient's  vitality 
and  hasten  the  fatal  result.  Unless  the  source  of  the  general  condition 
be  definitely  limited  to  the  wound  or  its  vicinity,  amputation  is  worse 
than  useless. 

CHRONIC  SEPTICAEMIA  OR   HECTIC  FEVER. 

The  condition  known  as  hectic  fever  is  really  a  chronic  septicaemia  ; 
it  may  follow  the  acute  form  in  a  few  rare  cases,  but  is  generally  chronic 
from  the  first.  It  is  marked  by  pyrexia,  night  sweats,  wasting,  and 
dryness  of  the  tongue,  and  usually  does  not  come  on  until  the  chronic 
septicaemic  condition  has  lasted  for  some  weeks  at  least.  The  tempera- 
ture has  a  distinctly  hectic  character,  being  high  in  the  evening  (101°  or 
102°  F.)  and  falling  to  about  normal  in  the  morning.  The  same  inter- 
mittent type  of  pyrexia  is  also  seen  in  acute  septicaemia,  but  there  the 
temperature  is  always  a  febrile  one,  notwithstanding  the  morning  fall. 
The  condition  used  to  be  ascribed  to  the  loss  of  certain  constituents  of 
the  blood  as  a  result  of  prolonged  suppuration.  There  can  be  no  doubt, 
however,  that  it  is  due  to  the  action  of  pyogenic  organisms,  which  appa- 
rently do  not  grow  in  the  blood  and  the  viscera,  as  they  probably  do  in 
acute  septicaemia,  but  are  located  mainly  in  the  wound.  After  hectic 
fever  has  lasted  for  some  time,  a  peculiar  degeneration  of  the  blood- 
vessels, termed  waxy  degeneration  or  lardaceous  disease,  takes  place,  and 
this  chiefly  affects  the  blood-vessels  in  the  liver,  the  kidneys,  and  the 
intestines  ;  as  a  result  of  this  there  is  polyuria,  albuminuria,  diarrhoea, 
and  oedema  of  the  extremities.  The  waxy  degeneration  is  due  to 
the  direct  action  of  the  poisonous  bacterial  products  circulating  in 
the  blood  upon  the  walls  of  the  blood-vessels  ;  it  is  not  due  to  the 
loss  of  the  purulent  fluid,  as  was  formerly  supposed.  The  affection 
is  most  frequently  met  with  in  association  with  tuberculous  disease  or 
necrosis  ;  it  was  formerly  a  common  sequela  of  operations  upon  psoas 
and  other  spinal  abscesses,  and  was  the  actual  cause  of  death  in  a  large 
number  of  those  cases. 

TREATMENT.— Local.— The  question  of  disinfecting  the  wound 
and  getting  rid  of  the  source  of  the  disease  is  naturally  the  first  to  arise. 


CHRONIC  SEPTICAEMIA   OR  HECTIC  FEVER  191 

From  this  point  of  view,  the  cases  may  be  divided  into  two  large  groups  : 
those  in  which  the  focus  of  the  disease  can  be  removed  entirely,  and 
those  in  which  this  is  impossible. 

When  the  Focus  of  Disease  can  be  removed  entirely. — These  cases 
may  be  subdivided  further  into  those  in  which  some  local  operation 
is  sufficient  to  get  rid  of  the  primary  disease,  and  those  in  which 
amputation  is  necessary. 

Local  operations,  such  as  the  removal  of  a  sequestrum  or  clearing 
out  of  a  joint,  are  called  for  when  the  extent  of  the  primary  disease  and 
the  anatomical  conditions  of  the  part  are  such  as  to  offer  a  good  chance 
of  removing  the  cause  of  the  mischief  completely  and  ensuring  thorough 
disinfection  of  the  tissues.  In  such  cases  the  whole  extent  of  the  wound 
should  be  opened  up,  and  left  open,  after  either  excising  the  focus  of  the 
disease  completely,  or  scraping  it  out  and  sponging  it  with  undiluted 
carbolic  acid  ;  all  the  recesses  of  the  wound  should  then  be  packed 
with  cyanide  gauze  sprinkled  with  iodoform.  The  outside  dressing  should 
consist  of  cyanide  gauze  and  salicylic  wool,  and  both  it  and  the  packing 
should  be  renewed  daily. 

Amputation  is  called  for :  (a)  when  the  primary  focus  can  only 
be  removed  by  amputating  the  limb,  and  (ft)  when  amputation  is  the 
only  safe  method  of  attaining  that  end. 

Perhaps  the  most  familiar  cases  in  which  amputation  is  obviously 
the  only  means  of  eradicating  the  primary  trouble  are  those  of  extensive 
disease — generally  tuberculous — of  the  knee,  ankle,  elbow,  or  wrist 
joints,  accompanied  by  widespread  suppuration  and  septic  sinuses  ;  any 
partial  operation  is  powerless  to  arrest  it,  and  nothing  but  an  amputa- 
tion performed  through  healthy  parts  will  avail. 

Sometimes  amputation  is  the  only  safe  method  of  treatment 
even  when  the  local  disease  is  small  in  extent.  Should  the  changes 
consequent  upon  the  occurrence  of  hectic  fever  be  so  far  advanced  that 
the  patient  is  completely  worn  out,  little  good  will  be  gained  by  any 
partial  operation.  Quite  apart  from  the  question  of  the  deleterious 
effects  of  the  shock  and  loss  of  blood,  which  are  often  considerable  in  an 
attempt  to  remove  the  diseased  parts  by  dissection,  the  patient's  con- 
dition is  such  that  he  cannot  bear  the  strain  of  a  prolonged  period  of 
healing,  and  amputation  therefore  offers  the  only  chance.  Although 
the  presence  of  waxy  degeneration  of  the  kidneys  was  supposed  formerly 
to  be  a  bar  to  amputation,  we  find  now  that  this  is  not  so  in  an  ampu- 
tation performed  antiseptically ;  not  only  does  the  hectic  fever  subside 
after  amputation,  but  the  waxy  condition  of  the  organs  tends  to  improve, 
the  liver  diminishes  in  size,  the  albumin  becomes  less,  and  may  ultimately 
disappear.  Therefore  amputation  is  clearly  indicated,  both  with  the  view 
of  saving  the  patient's  life  and  of  arresting  the  progress  of  the  disease. 

When  the  Local  Disease  cannot  be  removed  entirely. — The  greatest 
difficulty  occurs  when  the  source  of  infection  is  on  the  trunk— as,  for 


192  WOUNDS 

example,  in  psoas  abscess.  In  these  cases  it  is  impossible  to  remove  the 
source  of  infection  entirely,  but  nevertheless  the  only  chance  for  the 
patient  is  to  render  it  as  little  virulent  as  possible.  The  best  thing  is 
to  scrape  and  wash  out  the  wound  thoroughly  with  Barker's  flushing 
spoon  (see  Fig.  52)  and  i  in  6000  sublimate  solution,  and  then  to  fill  it 
with  iodoform  and  glycerine  emulsion  as  recommended  for  chronic 
abscess  (see  Chap.  XII.),  or  to  use  the  bismuth  mixture  referred  to 
in  connection  with  sinuses  associated  with  tuberculous  disease  of  bone 
(see  Vol.  II.). 

Another  example  in  which  treatment  is  very  difficult  is  tuberculous 
hip-joint  disease  in  which  the  pelvis  is  extensively  involved.  Here 
the  best  thing  probably  is  to  perform  amputation  at  the  hip  joint,  which 
serves  the  double  purpose  of  removing  a  considerable  portion  of  the 
diseased  tissues  and  allowing  free  access  to  the  mischief  in  the  pelvis. 
The  disease  may  be  completely  arrested  by  careful  removal  of  as  much  of 
the  affected  parts  as  possible,  followed  by  disinfection  and  free  drainage 
of  the  wound.  When  hectic  fever  results  from  long-standing  empyema, 
it  may  be  cured  by  bringing  about  closure  of  the  wound  by  Estlander's 
operation  (see  Empyema). 

General. — The  patient's  strength  must  be  supported  by  nourishing 
food,  fresh  air,  and  good  hygienic  conditions.  Tonics,  such  as  iron  and 
quinine,  will  be  useful,  and  stimulants  should  be  given  if  necessary. 

ACUTE  PYAEMIA. 

Pyaemia  is  the  gravest  of  the  infective  diseases  of  wounds  ;  it  usually 
comes  on  from  a  week  to  ten  days  after  an  operation  or  injury.  The 
traumatic  fever  has  generally  passed  off,  and  the  temperature  has  nearly 
reached  the  normal,  when  the  patient  suddenly  has  a  rigor,  which  may 
last  from  twenty  to  forty  minutes.  The  temperature  immediately  rises 
to  103°  or  104°  F.,  remains  at  that  point  for  perhaps  half  an  hour  or  more, 
and  then  begins  to  fall,  while,  coincident  with  the  fall,  there  is  profuse 
sweating.  The  phenomena  of  pyaemia  thus  closely  resemble  those  of 
ague :  there  is  first  the  cold  stage,  then  the  hot  one,  and  finally  the 
sweating.  The  temperature  may  fall  in  a  few  hours  after  the  attack 
to  what  it  was  before  the  onset  of  the  rigor,  or  even  to  normal,  and  for 
a  day  or  two  the  patient  may  seem  fairly  well.  Then  there  is  another 
rigor,  the  same  series  of  phenomena  recurs,  and  so  the  case  progresses, 
with  constantly  recurring  rigors,  the  intervals  between  which  steadily 
diminish,  while  the  temperature  in  the  intervals  does  not  fall  as  low  as 
before.  The  patient  often  becomes  jaundiced,  and  signs  of  abscesses  in 
the  lung,  joints,  etc.,  manifest  themselves,  albuminuria  develops,  and 
death  generally  occurs  about  eight  or  ten  days  after  the  first  onset  of  the 
disease. 

Although  it  is  probable  that  acute  pyaemia  is  due  essentially  to 


ACUTE  PYAEMIA  193 

the  same  organisms  as  those  that  cause  septicaemia,  the  two  affections 
differ  widely,  not  only  in  their  clinical  characters,  but  also  in  the  patho- 
logical changes  met  with.  From  the  point  of  view  of  treatment,  the 
pathological  condition  in  pyaemia  is  extremely  important.  The  disease 
is  undoubtedly  due  to  the  pyogenic  organisms,  the  one  most  frequently 
found  being  the  streptococcus  pyogenes.  The  lesions  found  after  death 
are  abscesses  in  various  organs,  and  suppuration  in  connection  with 
various  serous  membranes  ;  the  abscesses  are  most  numerous  in  the 
lung  in  the  majority  of  cases,  or  in  the  liver  if  the  wound  be  in  connection 
with  the  bowel.  The  pathology  of  pyaemia  is  apparently  that  a  vein  in 
the  neighbourhood  of  the  wound  becomes  inflamed  and  thrombosed  in 
the  first  place,  and  then  organisms  grow  in  the  thrombus  and  cause  it 
to  break  up  gradually.  Small  portions  containing  virulent  organisms 
are  carried  on  in  the  blood-stream  and  become  impacted  in  the  lungs  when 
the  thrombosis  is  in  one  of  the  systemic  veins,  or  in  the  liver  when  the 
primary  source  of  the  mischief  is  in  the  portal  area.  Here  probably  the 
same  process  is  repeated,  and  emboli  are  again  given  off  and  distributed 
by  the  arterial  circulation,  lodging  in  the  kidney,  the  spleen,  the  synovial 
or  the  serous  membranes,  etc.,  where  they  give  rise  to  abscesses.  These 
secondary  abscesses  may  also  be  caused  by  the  growth  of  streptococci  float- 
ing free  in  the  blood  ;  the  cocci  form  long  chains  which  coil  up  into  masses 
which  are  unable  to  pass  through  the  smaller  vessels,  in  which  therefore 
they  become  impacted.  The  most  important  point  with  respect  to  treat- 
ment is  that  the  disease  is  generally  associated  with  thrombosis  of  a  vein, 
and  is  due  to  detachment  of  portions  of  clot  from  the  blocked  vessel. 
Therefore,  the  disease  is  essentially  a  local  one,  in  its  earlier  stages  at 
any  rate,  and  can  be  effectively  treated  by  appropriate  local  measures. 

TREATMENT. — Local. — The  first  point  is  to  search  for  a  throm- 
bosed vein ;  in  the  extremities  this  will  probably  be  the  main  vein  of  the 
limb.  If  there  be  a  tender,  inflamed,  and  blocked  vein  in  the  neighbour- 
hood of  the  wound,  it  should  be  cut  down  upon  and  traced  upwards  to  a 
point  where  it  is  still  patent ;  a  double  ligature  is  put  on  it  there,  and  the 
vein  divided  between.  It  is  also  advisable  to  dissect  out  the  thrombosed 
vein  and  any  of  its  communicating  branches  which  may  be  similarly 
affected,  if  this  can  be  done.  If  this  be  done  when  the  patient  has  only 
had  one  or  two  rigors,  the  disease  may  be  arrested  completely ;  a  good 
example  of  what  can  be  done  by  this  method  of  treatment  is  seen  in 
pyaemia  following  thrombosis  of  the  lateral  sinus  due  to  otitis  media. 

Besides  removal  of  the  thrombosed  vein,  which  is  the  most  important 
part  of  the  treatment,  and  the  only  one  that  promises  anything  like  a 
radical  cure,  there  are  various  other  points  that  should  be  attended  to. 
The  wound  should  be  thoroughly  opened  up,  the  pus  washed  away,  the 
surface  sponged  with  undiluted  carbolic  acid,  and  the  granulations 
scraped  away  whether  the  vein  has  been  removed  or  not.  It  is  well  to 


i94  WOUNDS 

sponge  the  granulations  with  undiluted  carbolic  acid  before  scraping 
them  away,  so  as  to  get  rid  of  organisms  lying  upon  the  surface  which 
might  be  carried  by  the  sharp  spoon  into  the  deeper  tissues  ;  after  the 
granulations  have  been  removed,  the  raw  surface  left  should  be  swabbed 
over  again  with  the  undiluted  acid.  The  wound  should  then  be  packed 
with  cyanide  gauze  sprinkled  with  iodoform,  or  with  iodoform  gauze, 
and  a  gauze  and  wool  dressing  applied  outside.  The  packing  is  renewed 
daily  at  first,  and  then  at  longer  intervals,  if  the  case  does  well.  When 
a  fresh  layer  of  granulations  has  sprung  up,  the  packing  may  be  discon- 
tinued, a  large  drainage-tube  placed  in  the  wound  so  as  to  make  sure  that 
the  discharge  escapes  freely,  and  a  stitch  or  two  inserted  when  the  wound 
is  large.  If  the  patient  survive,  and  external  abscesses  develop,  they 
must  be  opened  early  and  drained  freely.  When  suppuration  occurs  in 
joints,  the  latter  must  be  opened  freely  and  drained  efficiently ;  this 
point  is  dealt  with  fully  in  connection  with  the  affections  of  joints. 
Further  details  as  to  local  treatment  in  special  cases  will  be  found  in 
connection  with  pyaemia  after  acute  osteomyelitis. 

When  there  is  no  wound,  and  the  pyaemia  has  started  from  a 
suppurative  periphlebitis,  the  vein  must  be  exposed  well  on  the 
proximal  side  of  the  thrombus  as  far  from  the  affected  spot  as  is 
judicious,  tied  in  two  places,  and  divided  between  the  ligatures.  An 
incision  must  then  be  made  over  the  seat  of  the  inflammation,  the  pus 
around  the  vein  evacuated,  and  the  part  containing  the  thrombus  excised, 
a  ligature  being  placed  on  the  distal  portion  of  the  vein.  If  it  be 
impossible  to  excise  the  vein,  it  should  be  opened,  and  the  clot 
removed  by  scraping  and  irrigation,  the  wound  being  then  packed  with 
gauze  wrung  out  of  an  antiseptic  (i  in  2000  perchloride  of  mercury). 
Any  branch  that  is  patent  should  be  also  ligatured  and  divided.  It  is 
very  important  not  to  be  content  with  simply  tying  the  main  vein, 
because  the  septic  clot  may  spread  to  other  veins  and  thus  get  into  the 
circulation  again. 

General. — Amongst  drugs,  the  greatest  reliance  is  placed  on  quinine. 
In  most  cases  it  is  well  to  begin  with  fifteen  to  twenty  grains  of  sulphate 
of  quinine,  and  to  follow  it  up  after  four  hours  with  five-  to  ten-grain 
doses  every  four  hours,  for  twenty-four  to  forty-eight  hours,  in  spite 
of  symptoms  of  cinchonism.  Salicylate  of  soda  (twenty  grains  every 
three  hours)  may  also  be  used,  but  the  patient  should  be  watched 
for  signs  of  salicylate  poisoning.  Sulpho-carbolates  have  been  suggested 
with  the  idea  that  carbolic  acid  would  be  liberated  in  the  blood,  and 
would  help  to  destroy  the  organisms  there  ;  as  a  matter  of  fact,  however, 
the  amount  of  carbolic  acid  that  could  be  thus  liberated  would  have 
no  effect,  and  in  practice  the  sulpho-carbolates  are  useless. 

Antipyretic  measures  must  be  employed  when  the  temperature  is 
unusually  high,  because  the  patient  may  die  of  the  hyperpyrexia  after  a 
rigor.  Phenacetin  in  five-  or  ten-grain  doses  is  perhaps  the  safest  of  the 
antipyretic  drugs,  and  it  may  be  repeated  every  hour  if  necessary,  the 


CHRONIC  PY^MIA 


195 


pulse  being  watched  meanwhile  for  any  sign  of  depression.  Antipyrin 
is  no  doubt  a  still  more  effectual  antipyretic,  but  it  is  a  powerful  de- 
pressant, and  may  produce  an  alarming  degree  of  collapse  if  the  patient 
be  weakly.  Sponging  the  body  with  water  at  about  90°  F.  is  a  rapid 
and  effectual  way  of  reducing  the  temperature  ;  it  is  agreeable,  and  not 
depressing.  The  patient  should  lie  naked  between  blankets,  and  the 
sponging  should  be  done  under  the  blanket  without  exposing  the  surface 
of  the  body  to  the  cold  air ;  it  should  be  continued  for  about  fifteen 
minutes,  and  the  skin  should  be  then  dried  with  soft  towels.  Care  must 
be  taken  to  maintain  the  temperature  of  the  water  used  for  sponging. 
Sponging  should  be  repeated  whenever  the  temperature  rises  above 
102°  F.  Rectal  saline  injections  administered  by  the  drop  method 
(see  p.  115)  are  often  of  great  value. 

Stimulants  will  also  be  necessary,  but  they  should  not  be  pushed  to 
extremes,  in  the  early  stage  at  any  rate ;  about  six  ounces  of  brandy 
should  be  given  in  the  twenty-four  hours.  A  larger  quantity  may  be 
required  at  a  later  period,  when  champagne  is  specially  useful  given  with 
or  immediately  after  food. 

A  liquid  diet  should  be  given  ;  solids  only  accumulate  in  the  intestines 
and  upset  the  digestive  organs.  Milk  (which  may  be  combined  with  a 
few  drops  of  saccharated  lime  water  to  prevent  curdling,  or  with  sodium 
citrate  gr.  j  ad  §j)  and  meat  juices  should  be  given  in  small  quantities  fre- 
quently repeated.  About  four  pints  of  milk  and  a  pint  and  a-half  of  strong 
beef  tea  should  be  given  in  the  twenty-four  hours,  with  a  teaspoonful  of 
meat  juice  every  four  hours.  Citric  acid  and  citrates  are  also  of  value. 

The  question  of  vaccines  in  acute  pyaemia  is  dealt  with  in  the 
Appendix.  Though  they  are  sometimes  of  value,  the  dose  must  be  deter- 
mined very  carefully,  for  if  this  be  too  large  much  harm  may  be  done. 

CHRONIC  PY^MIA. 

Besides  the  acute  form  of  pyaemia  described  above,  there  are  various 
chronic  types  which  are  associated  with  other  organisms,  particularly  the 
pneumococcus.  It  often  happens  that,  although  repeated  abscesses 
form  and  the  disease  is  very  protracted,  the  internal  organs  remain  free 
from  infection  ;  this  form  is  termed  external  pyaemia.  There  may  also 
be  a  remarkable  restriction  of  the  infection  in  some  cases  to  one  type  of 
tissue ;  for  example,  a  primary  abscess  in  a  joint  may  be  followed  by 
secondary  abscesses  in  other  joints,  the  bone  and  subcutaneous  tissues 
remaining  healthy,  while  in  other  cases  the  skin  only  is  affected  and  there 
may  be  a  large  number  of  abscesses  in  the  skin  and  subcutaneous  tissue 
without  any  infection  of  bone,  joints,  or  viscera.  Secondary  abscesses  may 
follow  immediately  upon  the  primary  one,  or  there  may  be  a  quiescent  interval 
between  them  ;  this  condition  is  most  commonly  met  with  in  children. 

TREATMENT. — Any  external  abscess  will  require  to  be  opened. 
Any  joint  that  becomes  infected  must  be  fixed  upon  a  splint,  opened  freely, 
and  a  drainage-tube  inserted.  The  patient  is  usually  not  in  a  condition 


196  WOUNDS 

to  bear  any  more  severe  procedure,  but  free  drainage  of  the  joint  often 
suffices ;  in  these  successful  cases  the  patient  may  even  recover  the  full 
movements  of  the  joint.  The  injection  of  antistreptococcic  serum  has 
been  tried  in  these  cases,  but  it  is  difficult  to  say  much  about  its  value. 
If  it  be  used,  full  doses  should  be  given  twice  a  day  for  three  or  four  days 
(see  p.  173) .  These  cases  are,  however,  much  more  suitable  for  treatment 
by  vaccines  (see  Appendix)  than  by  serum. 

ERYSIPELAS. 

Erysipelas  is  a  febrile  disease  caused  by  a  streptococcus,  and  charac- 
terised by  a  well-defined  spreading  redness  of  the  skin. 

SYMPTOMS. — The  disease  usually  commences  from  four  days  to 
a  week  after  the  operation  or  injury,  but  it  may  occur  as  early  as  the  first 
or  the  second  day. 

The  wound  through  which  the  organisms  gain  entrance  to  the  lym- 
phatics need  not  be  extensive  ;  it  is  often  a  mere  prick  with  an  infected 
instrument,  or  an  insect  bite,  and  may  have  healed  completely  before 
the  onset  of  the  disease. 

There  are  usually  certain  premonitory  symptoms  preceding  the 
actual  attack,  such  as  malaise,  headache,  loss  of  appetite,  and  a  feeling 
of  tension  and  pain  about  the  wound ;  this  may  be  followed  by  a  rigor. 
In  other  cases  the  disease  may  begin  suddenly  with  a  severe  rigor,  without 
any  premonitory  symptoms.  However  it  may  be  ushered  in,  the  attack 
is  followed  by  a  rapid  rise  of  temperature  to  about  104°  F.,  headache, 
nausea  or  vomiting,  a  rapid  soft  pulse,  a  foul  tongue,  great  thirst,  scanty 
urine,  diminution  of  the  discharge  from  the  wound,  and  swelling  of  the 
neighbouring  lymphatic  glands,  to  which  there  may  be  red  lines  running 
from  the  wound.  Occasionally  there  is  active  delirium.  In  from  ten 
to  twenty-four  hours  after  the  rigor  a  dark  red  or  crimson  blush,  which 
is  sharply  marked  off  from  the  surrounding  parts,  appears  around  the 
wound,  and  the  reddened  portion  is  somewhat  swollen.  The  redness 
increases  and  usually  spreads  along  the  course  of  the  lymphatic  vessels — 
that  is  to  say,  towards  the  trunk.  The  margin  of  the  rash  can  be  felt 
as  a  distinct  raised  ridge.  Where  the  tissues  are  lax,  as  in  the  eyelids 
or  the  scrotum,  the  swelling  may  be  very  great,  and  bullae  may  form 
upon  the  surface  ;  bullae  may  also  appear,  although  not  so  frequently, 
when  the  trunk  or  limbs  are  affected.  During  the  course  of  the  disease 
there  is  often  albuminuria.  In  about  six  or  eight  days  there  is  generally 
a  rapid  fall  of  the  temperature,  which  has  remained  high  during  the  acute 
period.  The  constitutional  phenomena  disappear,  the  appetite  im- 
proves, the  redness  gradually  fades,  and  usually  dies  away  by  the  middle 
of  the  second  week  ;  finally  desquamation  occurs.  This  desquamation 
is  of  great  importance,  because  it  is  in  the  scales  of  epidermis  that  the 
chief  source  of  the  erysipelas  infection  is  to  be  found.  After  recovery 
recrudescence  of  the  disease  is  common.  In  bad  cases  the  disease 


ERYSIPELAS  197 

may  end  fatally   during  the   second  week  from  pyrexia  and  general 
exhaustion. 

VARIETIES. — This  disease  is  seldom  seen  nowadays,  and  the  form 
usually  met  with  is  the  mild  one  which  ends  in  recovery.  In  one  type 
the  disease  reappears  frequently  but  with  ever-decreasing  constitutional 
disturbance ;  this  is  sometimes  spoken  of  as  habitual  erysipelas. 
Formerly  a  number  of  other  varieties  were  described,  such  as  wandering 
erysipelas  in  which  a  patch  of  erysipelas  appeared  at  one  spot,  and  died 
away,  and  fresh  patches  appeared  elsewhere,  constitutional  symptoms 
showing  themselves  as  each  fresh  patch  appeared.  The  most  serious  forms 
were  described  as  phlegmonous  and  gangrenous  erysipelas  ;  in  these,  in 
addition  to  the  symptoms  already  described,  there  was  suppuration  in  the 
subcutaneous  tissues,  which  sometimes  took  the  form  of  an  abscess,  but 
more  commonly  manifested  itself  as  a  diffuse  cellulitis ;  occasionally  the 
skin  and  the  deeper  tissues  sloughed.  In  these  cases  the  patient  soon 
passed  into  a  typhoid  state,  and  often  died. 

It  is  a  question  whether  these  gangrenous  and  phlegmonous  varieties 
of  erysipelas  are  due  solely  to  the  erysipelas  organism,  or  whether  there 
is  a  mixed  infection,  the  erysipelas  organism  growing  in  the  skin,  and 
the  streptococcus  pyogenes  in  the  deeper  structures.  The  majority  of 
investigators  incline  to  the  opinion  that  the  streptococcus  pyogenes  and 
the  erysipelas  organism  are  identical  and  are  only  slightly  modified  in 
virulence ;  according  to  this  theory,  phlegmonous  erysipelas  is  regarded 
as  a  more  virulent  form  than  the  one  commonly  seen  nowadays.  In 
favour  of  the  theory  of  a  mixed  infection  is  the  fact  that  diffuse  cellulitis 
may  occur  without  cutaneous  erysipelas,  and  vice  versa  ;  besides  this, 
there  are  points  in  the  bacteriological  history  of  the  organisms  which 
seem  to  indicate  a  distinct  though  slight  difference. 

Pathology. — The  streptococcus  which  causes  the  disease  spreads  in 
the  cutaneous  lymphatic  vessels,  and  is  found  in  the  skin  immediately 
beyond  the  edge  of  the  blush ;  the  organisms  are  always  a  little  in  advance 
of  the  visible  disease.  At  the  edge  of  the  blush  the  lymphatic  vessels 
are  found  full  of  micrococci  and  of  leucocytes,  while  nearer  the  centre 
of  the  redness  the  micrococci  have  disappeared  and  only  leucocytes 
are  found.  Erysipelas  therefore  presents  one  of  the  best  examples 
of  phagocytosis,  the  phagocytes  attacking  and  destroying  the  organisms 
and  putting  a  stop  to  their  action.  This  view  may  possibly  help  to 
explain  the  results  of  treatment. 

TREATMENT. — The  prophylaxis  is  extremely  important,  and, 
as  erysipelas  is  never  met  with  in  aseptic  wounds,  it  is  of  the  utmost 
importance  to  secure  the  asepsis  of  all  wounds. 

General. — The  mild  form  usually  met  with  nowadays  generally 
subsides  spontaneously.  Provided  that  there  be  no  internal  complica- 
tion, such  as  visceral  disease,  it  suffices  to  administer  a  saline  purgative 
(sulphate  of  magnesia  3ij-iv)  and  to  see  that  the  bowels  are  afterwards 
kept  open  daily  with  drachm  doses  of  the  same  drug  in  warm  water 


198  WOUNDS 

the  first  thing  in  the  morning.  A  pleasant  aperient  is  effervescing  sulphate 
of  soda  (3j),  or  a  Seidlitz  powder.  Quinine  (gr.  j-ij)  every  four  hours  and 
tincture  of  perchloride  of  iron  (H\xv  in  water)  every  three  hours  are  looked 
upon  as  being  of  special  value.  The  diet  should  consist  of  milk,  beef  tea, 
or  strong  soups. 

Local. — In  the  more  severe  forms  of  erysipelas  it  is  important 
to  make  the  most  strenuous  efforts  to  check  the  local  progress  of  the 
disease.  In  former  days  a  favourite  plan  was  to  draw  a  line  on  the  skin 
around  and  just  in  front  of  the  area  of  the  redness  with  solid  nitrate  of 
silver,  or  to  paint  on  liniment  of  iodine  in  a  similar  manner,  and  it  was 
found  that  the  erysipelas  stopped  at  this  line  in  a  certain  number  of 
cases  and  seemed  unable  to  cross  it.  At  first  sight  this  treatment  does  not 
seem  very  rational,  but  if  we  bear  in  mind  what  has  just  been  said  as  to 
the  relation  of  erysipelas  to  phagocytosis  it  becomes  explicable  and  logical. 
If  the  skin  be  irritated  with  nitrate  of  silver  or  strong  iodine,  increased 
leucocytosis  will  occur  in  the  part,  and  if  this  be  done  a  day  or  two  before 
the  erysipelas  organisms  reach  the  area  to  which  the  irritant  has  been 
applied,  they  will  find  the  tissues  and  vessels  blocked  with  large  numbers 
of  leucocytes,  the  phagocytic  action  of  which  may  suffice  to  prevent  their 
further  spread.  It  seems  probable  that  one  reason  why  this  method  did 
not  succeed  uniformly  is  that  the  application  was  not  always  made 
sufficiently  early  or  far  enough  away  from  the  spreading  margin  to  ensure 
an  adequate  leucocytosis  in  the  part  before  the  organisms  reached  it.  The 
method  may  be  of  value  if  care  be  taken  to  apply  the  irritant  very 
thoroughly  at  some  considerable  distance  from  the  edge  of  the  redness. 
Kraske's  method,  which  at  the  present  time  seems  to  promise  best, 
probably  acts  on  the  same  principle. 

Kraske's  method  consists  in  making  numerous  small  scarifications  in 
the  skin  at  some  distance  beyond  the  spreading  edge  of  the  erysipelas, 
just  deep  enough  to  draw  blood.  The  scarifications  should  be  very 
numerous,  and  should  cross  each  other  and  surround  the  entire  reddened 
area  about  two  inches  from  its  edge  (see  Fig.  56) ;  after  oozing  has  ceased, 
the  affected  area  is  either  soaked  or  sprayed  with  a  i  in  20  carbolic  acid 
solution  for  an  hour.  Then  compresses  of  gauze  soaked  in  i  in  40  carbolic 
acid  solution  are  applied  over  the  scarified  surface.  Partly  as  the  result 
of  the  scarifications  and  partly  as  the  result  of  the  carbolic  acid,  con- 
siderable irritation  is  produced  all  round  the  erysipelatous  area,  and,  as 
suggested  above,  when  the  organisms  reach  the  irritated  part  they  are 
met  by  a  barrier  of  cells.  Certainly  experience  seems  to  show  that 
Kraske's  method  is  the  most  effectual  plan  of  treating  erysipelas,  so  long 
as  the  affection  is  a  true  cutaneous  one  and  does  not  involve  the  sub- 
cutaneous tissues  as  well.  It  should  only  be  used  in  severe  cases,  however, 
as  it  is  painful,  and  an  anaesthetic  is  required  during  the  scarification. 

Among  the  many  applications  to  the  actual  erysipelatous  area  advo- 
cated by  various  authorities,  perhaps  the  best  is  ichthyol,  which  can  be 


TETANUS 


199 


applied  in  watery  solution  (10  to  25  per  cent.).  Some  surgeons  state 
that  they  have  got  good  results  by  spraying  the  affected  area  freely  with 
carbolic  acid,  upon  the  presumption  that  the  acid  is  absorbed  by  the  lym- 
phatic vessels,  and  thus  directly  affects  the  organisms ;  probably  this  idea 
has  no  good  foundation  in  fact.  In  most  cases  applications  calculated 
to  relieve  the  local  discomfort  are  sufficient.  When  there  is  neither 
much  heat  nor  pain,  all  that  is  necessary  is  to  wrap  the  part  up  in  sali- 
cylic wool.  When  both  pain  and  swelling  are  present,  lead  lotion  or 
lead  and  opium  lotion  (see  p.  9)  is  to  be  recommended ;  lint  kept 
constantly  moist  with  the  lotion  should  be  placed  over  the  affected 
area.  During  desquamation  it  is  well  to  keep  the  part  anointed  with 
some  antiseptic  ointment,  such  as  the 
ung.  eucalypti.  This  relieves  the 
troublesome  itching  often  complained 
of,  and  lessens  the  chance  of  dissemina- 
tion of  the  infective  epidermic  scales. 

In  a  case  of  the  so-called  phlegmo- 
nous  or  gangrenous  erysipelas,  the  treat- 
ment is  identical  with  that  of  diffuse 
cellulitis  (see  p.  31).  Free  incisions 
should  be  made  into  the  part  in  all 
directions  so  as  to  allow  the  escape  of 
the  discharge,  and  this  should  be  fol- 
lowed by  constant  irrigation  (see  p.  32). 

The  advisability  of  using  antistrep- 
tococcic  serum  in  this  affection  must 
also  be  borne  in  mind ;  so  far  the 
results  obtained  from  it  have  not  been 
encouraging.  At  the  same  time,  it 
does  not  seem  to  do  any  harm,  and 
therefore  any  of  the  forms  of  treat- 
ment mentioned  above  may  well  be  accompanied  by  the  injection  of 
20  c.c.  of  the  serum  at  present  supplied  by  the  Lister  Institute  of 
Preventive  Medicine ;  half  that  quantity  should  be  given  again  in 
twelve  hours,  while  a  third  dose  may  be  given  twelve  hours  later  (see 
also  p.  173). 

TETANUS. 

Tetanus  is  an  infective  disease  of  wounds  due  to  a  special  bacillus 
and  characterised  by  painful  tonic  contractions  of  the  muscles  with 
convulsive  exacerbations ;  the  contractions  commence  in  the  muscles 
of  the  jaw  and  neck,  and  spread  to  all  the  voluntary  muscles  of  the  body. 

SYMPTOMS.— The  affection  usually  begins  between  the  fifth  and 
fifteenth  day  after  the  infliction  of  the  wound.  Preceding  the  onset  of 


FIG.  56. — KRASKE'S  TREATMENT  FOR  ERY- 
SIPELAS.— There  should  be  a  clear  interval  of 
two  inches  between  the  ring  of  scarifications 
and  the  margin  of  the  rash. 


200  WOUNDS 

the  disease,  there  are  often  prodroniata,  such  as  a  feeling  of  malaise,  a 
tendency  to  yawn,  headache,  fear  on  the  part  of  the  patient  that  he  will 
not  get  better,  and  neuralgic  pains  in  the  wound  radiating  along  the  nerves 
and  accompanied  by  local  spasms  or  cramps. 

Shortly  after  the  appearance  of  these  premonitory  symptoms  the 
typical  symptoms  of  tetanus  set  in ;  the  muscles  of  mastication  are  generally 
affected  first  and  the  condition  known  as  Irismus  is  produced.  The 
masticators  contract  and  more  or  less  fix  the  jaw,  and  convulsive  con- 
tractions of  these  muscles  occur  on  any  attempt  to  open  the  mouth  to 
eat  or  drink.  The  spasm  next  attacks  the  muscles  of  the  neck,  resulting 
/n  fixation  of  the  head,  and  about  the  same  time  the  muscles  of  expression 
also  become  affected,  giving  rise  to  the  risus  sardonicus,  in  which  the 
angles  of  the  mouth  are  drawn  out,  the  alae  of  the  nose  elevated,  the  eyes 
widely  opened,  and  the  forehead  wrinkled.  The  next  set  of  muscles 
affected  is  generally  the  pharyngeal  group,  leading  to  spasmodic  dys- 
phagia.  Soon  the  voluntary  muscles  elsewhere  are  attacked,  generally 
in  groups,  those  next  affected  being  usually  the  sacro-lumbar  muscles 
and  those  of  the  lower  extremities,  leading  to  opisthotonos ;  then  the 
muscles  of  the  upper  extremity,  those  of  the  abdomen,  and,  fortunately 
last  of  all,  the  muscles  of  respiration.  The  muscular  spasm  seldom 
relaxes  altogether,  while  the  least  movement  or  disturbance  of  the  patient 
is  apt  to  set  up  clonic  contractions — the  well-known  tetanic  spasms.  The 
pulse  generally  varies  from  100  to  140  ;  the  temperature  is  usually  up 
to  104°  F.,  being  highest  during  the  convulsions.  When  the  temperature 
goes  higher  than  104°  or  105°  the  condition  is  generally  very  grave,  and 
the  pyrexia  may  end  fataUy  unless  steps  be  taken  to  reduce  it.  The 
respirations  are  normal,  but  increase  hi  frequency  during  the  attack  ;  the 
patient  cannot  swallow,  the  saliva  runs  out  of  the  mouth,  there  is  diminu- 
tion in  the  amount  of  the  urine  but  no  albuminuria,  and  there  is  profuse 
sweating  after  the  convulsions. 

The  principal  causes  of  death  in  this  disease  are  :  severe  laryngeal 
spasm,  terminating  in  fatal  asphyxia,  spasm  of  the  diaphragm  or  other 
respiratory  muscles,  arrest  of  the  heart's  action  due  to  spasm  or  paralysis, 
profound  exhaustion  and  inanition,  and  hyperpyrexia. 

VARIETIES. — Tetanus  may  be  acute  or  chronic.  The  acute  form 
accompanied  by  high  temperature  usually  ends  fatally  in  four  days,  and 
only  about  one  per  cent,  of  those  affected  with  this  form  recover  under 
ordinary  treatment.  In  the  more  chronic  variety  the  onset  is  more 
delayed,  and  the  characteristic  symptoms  of  the  disease  may  not  become 
manifest  for  two  or  three  weeks  ;  the  convulsions  are  less  frequent,  and 
not  so  general.  This  form  may  become  acute,  however,  and  death  then 
takes  place  rapidly  ;  about  twenty  per  cent,  of  the  patients  recover. 

CAUSES. — Tetanus  most  commonly  occurs  after  wounds  of  the 
extremities.  It  is  due  to  a  bacillus  which  is  anaerobic  and  spore-bearing, 
and  which  is  commonly  found  in  garden  earth,  in  horse-dung,  and  generally 


TETANUS  201 

in  places  soiled  with  the  latter.  The  reason  why  it  occurs  especially  after 
wounds  in  the  extremities  is  that  they  are  more  likely  to  be  soiled  ; 
although  tetanus  most  frequently  occurs  as  a  complication  of  lacerated 
wounds,  it  may  follow  a  mere  scratch.  It  is  not  the  amount  of  laceration 
of  a  wound  that  is  of  consequence,  but  the  soiling  of  it  with  earth.  No 
doubt  the  soiling  is  more  likely  to  be  great  when  the  wound  is  torn  than 
when  it  is  simply  a  clean  incision.  In  infants  infection  may  take  place 
through  the  umbilical  cord — '  tetanus  neonatorum.' 

TREATMENT. — Prophylactic. — As  tetanus  is  unknown  in  aseptic 
wounds,  it  is  clear  that  strict  purification  of  wounds  likely  to  be  infected 
with  the  tetanus  bacillus  must  be  of  the  first  importance.  Hence  all 
wounds  that  are  soiled  with  earth,  or  that  have  occurred  from  falls  in 
stables,  gardens,  and  so  forth,  must  be  thoroughly  purified,  a  nail-brush 
being  used  to  scrub  away  the  earth,  and  the  whole  wound  thoroughly 
sponged  with  undiluted  carbolic  acid.  (For  further  details  see  p.  171.) 
Moreover,  since  the  symptoms  of  tetanus  are  really  those  of  the  late  stage 
of  the  disease,  when  severe  injury  has  been  inflicted  by  the  toxins  upon 
the  nervous  system,  it  is  well  to  administer  10-20  c.c.  of  anti-tetanic 
serum  in  any  case  in  which  there  is  reason  to  suspect  that  the  wound  may 
be  infected  with  the  bacillus,  without  waiting  for  the  typical  symptoms  to 
develop.  This  avoids  the  risk  of  the  nervous  phenomena  persisting  after 
the  tetanus  toxin  has  been  satisfactorily  neutralised  by  the  anti-tetanic 
serum. 

Curative. — -When  the  disease  is  established,  anti-tetanic  serum  is 
undoubtedly  effectual  in  a  number  of  cases,  and  should  be  employed  at 
once.  It  is  the  serum  of  horses,  or  other  animals  which  have  been 
rendered  immune  to  tetanus,  and  is  injected  subcutaneously.  It  is  well 
to  begin  with  20  c.c.  of  the  serum  prepared  by  the  Lister  Institute,  and 
to  repeat  the  dose  in  from  twelve  to  twenty-four  hours,  according  to  its 
effect  on  the  spasms.  The  administration  should  be  repeated  every 
twelve  or  twenty-four  hours  if  necessary. 

The  failure  which  has  often  followed  subcutaneous  injection  of  the 
serum  when  the  disease  is  well  developed  has  led  to  the  practice  of 
injecting  it  into  the  central  nervous  system  itself.  The  serum  may  be 
injected  into  the  subarachnoid  space  by  means  of  lumbar  puncture,  but  the 
most  certain  method  is  to  inject  it  into  the  substance  of  the  cerebral 
hemisphere  itself.  This  method  is  not  as  dangerous  as  it  would  at  first 
sight  appear  ;  the  cerebral  tissue  is  comparatively  loose,  and  in  one 
case,  which  ended  fatally,  and  in  which  5  c.c.  had  been  injected  into  the 
frontal  lobe,  no  trace  of  the  injection  could  be  found  post-mortem.  It 
is  well,  however,  to  make  the  injection  beneath  a  silent  area  of  the  cortex 
where  destruction  of  a  few  fibres  will  lead  to  no  symptoms.  The  adminis- 
tration of  chloroform  is  no  drawback,  since  it  is  often  called  for  to  allay 
the  spasms. 

The  head  is  shaved,  and  a   curved   incision   is  made  through   the 


202 


WOUNDS 


scalp  in  the  frontal  region,  just  within  the  line  of  the  hair;  a  flap  is 
turned  down  so  as  to  allow  a  half-inch  trephine  hole  to  be  cut  in 
the  skull.  The  circle  of  bone  is  removed,  a  hypodermic  needle  is 
pushed  through  the  dura  into  the  brain  and  5  c.c.  of  the  serum 
are  injected  slowly.  The  needle  is  withdrawn  and  the  wound  sutured 
without  replacing  the  crown  of  bone  ;  a  similar  operation  is  then  per- 
formed on  the  opposite  side.  The  opening  in  the  skull  can  be  felt 
clearly  through  the  scalp,  and  it  is  easy  to  give  a  second  dose,  should 
one  be  required,  without  re-opening  the  wound,  by  thrusting  the  needle 
through  the  skin  into  the  brain.  It  is  thus  possible  to  bring  the  anti- 
toxin into  actual  contact  with  the  poisoned  nerve-cells  and  in  some  cases 

with  very  satisfactory  re- 
sults. The  effect  of  the 
serum  is  sometimes  very 
remarkable,  but  it  is  not 
immediate,  and  in  spite  of 
its  use  the  spasms  may  recur 
so  severely  as  to  require  the 
administration  of  chloro- 
form ;  they  are  usually, 
however,  at  longer  intervals 
and  less  severe. 

Treatment  of  the 
Wound. — We  do  not  know 
the  exact  modus  operandi  of 
the  tetanus  bacillus,  though 
it  is  seldom  limited  to  the 
wound ;  but  nevertheless  it 
is  well  in  the  early  stage  to 
give  the  patient  chloroform, 

open  up  the  wound  and  wash  away  all  decomposing  material,  and  then 
to  clip  away  any  gangrenous  shreds,  thoroughly  sponge  the  wound  out 
with  pure  carbolic  acid,  and  pack  it  with  cyanide  gauze  sprinkled  with 
iodoform.  The  dressing  then  need  not  be  disturbed  for  two  or  three  days, 
so  that  the  patient  is  saved  the  pain  and  the  risk  of  convulsions  involved 
in  attention  to  the  wound.  Amputation  is  frequently  performed  in  cases 
of  wounds  of  the  extremities," but,  as  the  disease  has  generally  established 
itself  in  the  system,  the  operation  is  useless,  and  may  be  hurtful  from  the 
pain  and  disturbance  it  causes.  If  anything  is  to  be  effected  by  local 
treatment  it  will  be  done  as  effectually  by  thorough  disinfection  of  the 
wound  as  by  amputation,  and  with  less  risk  to  the  patient. 

Drugs. — Whether  the  serum  be  injected  or  not.  it  is  necessary  to 
administer  sedatives,  and  the  one  most  in  vogue  is  chloral  in  large  doses ; 
an  adult  may  have  as  much  as  150  or  even  200  grains  in  the  course 
of  twenty-four  hours.  Care  must  be  taken  not  to  poison  the  patient  with 


FIG.  57. — INTRA-CEREBRAL  INJECTION  OF  ANTI-TETANIC 
SERUM. — On  the  left  side  the  incision  is  shown  ;  on  the  right 
side  the  flap  has  been  turned  down,  the  circle  of  bone 
removed  and  the  injecting  needle  thrust  vertically  through  the 
dura  mater. 


IJ 


J  J  0  3 


TETANUS 


203 


the  drug,  as  has  undoubtedly  happened,  but  usually  the  amount  men- 
tioned can  be  administered  in  the  course  of  twenty-four  hours  without 
risk  ;  when  there  is  inability  to  swallow,  it  may  be  administered  by  the 
rectum.  Since  the  slightest  noise  or  disturbance  is  likely  to  bring  on  a 
spasm,  the  patient  should  be  completely  isolated  in  a  thickly  carpeted 
room,  and  complete  silence  should  be  maintained  ;  it  is  well  to  wrap  all 
the  exposed  portions  of  the  body  in  cotton-wool,  so  as  to  avoid  irritation 
to  the  surface  of  the  skin  from  the  impact  of  cold  air,  etc. 

When  the  spasms  are  very  severe  and  threaten  to  produce  dangerous 
hyperpyrexia,  or  to  cause  death  from  obstruction  to  the  respiration, 
chloroform  should  be  administered.  The  spasm  rapidly  subsides  under 
the  influence  of  the  anaesthetic,  and  repeated  administrations  may  be 
called  for  in  bad  cases.  When  the  patient  is  unable  to  swallow,  advantage 
should  be  taken  of  the  administration  of  the  anaesthetic  to  introduce 
suitable  nourishment  into  the  stomach  by  means  of  a  stomach-tube  ; 
the  opportunity  may  also  be  taken  to  give  a  nutrient  enema.  Morphine, 
in  doses  of  one-sixth  of  a  grain,  may  also  be  given  subcutaneously  every 
three  or  four  hours  ;  but  among  drugs  the  chief  reliance  is  to  be  placed  on 
chloral  and  chloroform. 

When  hyperpyrexia  occurs,  the  temperature  should  be  reduced  by 
sponging  with  tepid  water  or  by  cold  wet  packing.  The  former  of  these 
methods  is  preferable,  as  cold  water  is  apt  to  set  up  a  spasm.  Should 
sponging  fail  to  reduce  the  temperature,  it  will  be  necessary  to  have 
recourse  to  wet  packing,  which  is  done  as  follows.  A  mackintosh 
is  put  under  the  patient,  who  is  then  wrapped  up  in  a  sheet  wrung  out  of 
iced  water.  A  blanket  is  thrown  over  him  and  he  is  left  in  the  wet  pack 
for  from  five  to  fifteen  minutes.  Then  the  sheet  and  the  mackintosh  are 
removed,  and  the  patient  is  dried  and  covered  with  the  bedclothes. 

Diet. — The  strength  should  be  kept  up  as  far  as  possible  by  proper 
nourishment ;  the  great  majority  of  cases  in  which  the  patient  cannot 
swallow  end  fatally.  If  the  patient  cannot  swallow,  and  especially  if 
the  attempts  to  do  so  produce  convulsions,  it  is  necessary  to  resort  to 
rectal  feeding ;  care  must  be  taken,  however,  to  disturb  the  patient  as 
little  as  possible  in  introducing  the  food  into  the  rectum.  For  this 
purpose  zyminised  suppositories  are  of  great  value  ;  one  should  be  intro- 
duced every  four  hours,  and  a  two  ounce  beef-tea  enema  should  be 
given  every  two  hours  after  the  suppository ;  it  is  best  to  peptonise 
it  before  it  is  introduced.  Later  on  in  the  disease,  when  the  patient  is 
becoming  exhausted,  it  may  be  necessary  to  add  stimulants  to  the  enemata. 
Watch  should  be  kept  to  see  that  the  urine  is  passed,  for  the  bladder  is 
apt  to  become  distended ;  the  bowel  should  be  washed  out  with  an 
injection  of  warm  water  from  time  to  time.  Above  all  things,  care 
should  be  taken  to  avoid  all  sudden  movements,  and  to  be  as  gentle  as 
possible  in  handling  the  patient. 


CHAPTER    X. 
AFFECTIONS  OF    CICATRICES. 

CHELOID. 

ALTHOUGH  the  cicatrix  is  usually  healthy  when  union  by  first  intention 
has  occurred,  this  is  not  invariably  the  case,  and  when  a  large  wound 
has  been  allowed  to  heal  by  granulation,  the  scar  left  is  often  unsatis- 
factory. In  either  case  the  condition  known  as  false  cheloid  or  thickened 
cicatrix  may  be  met  with.  The  cicatrix  becomes  thickened  and  raised 
above  the  surface  of  the  surrounding  skin  ;  when  the  scar  is  linear  there 
is  a  hard  raised  bar  of  this  cheloid  material,  corresponding  to  the 
line  of  incision,  and  when  it  is  a  broad  one  the  affection  generally 
begins  at  the  junction  of  the  skin  with  the  cicatricial  tissue,  and  spreads 
thence  through  the  rest  of  the  scar.  When  the  scar  is  broad,  a  most 
unsightly  deformity  is  produced,  as  the  surrounding  parts  are  pulled 
upon  and  puckered  up.  The  scar  does  not  yield  as  ordinary  scar 
tissue  should,  and  the  cheloid  itself  is  painful,  and  liable  to  become 
ulcerated. 

CAUSES. — The  cause  of  this  condition  is  by  no  means  clear.  Small 
cheloids  are  sometimes  found  on  the  back  of  the  wrists,  produced  by  the 
chafing  of  the  patient's  cuffs,  and  there  is-  a  type  of  cheloid  found  over 
the  manubrium  sterni — Alibert's  cheloid — which  does  not  seem  to  be 
associated  with  a  wound.  It  is  probable  that  slight  sepsis  is  a  factor  in 
the  production  of  cheloid  in  many  cases ;  for  example,  after  operations 
in  which  slight  infection  has  been  suspected  and  a  drainage-tube  has  been 
used,  it  is  not  uncommon  to  find  a  cheloid  scar  at  the  site  of  the 
drainage-tube,  while  that  of  the  rest  of  the  wound  is  quite  supple.  It 
is  most  common  after  operations  on  tuberculous  patients,  though  there 
is  no  evidence  that  the  affection  is  tuberculous,  and  in  these  patients  it 
is  not  uncommon  to  find  that  every  scar — even  down  to  a  pin-  or 
needle-prick — becomes  cheloid.  The  microscope  reveals  simply  a  large 
number  of  young  cells  and  granulation-tissue. 

204 


CHELOID  205 

Cheloid  scars  often  disappear  in  the  course  of  time,  but  such  a 
termination  is  uncertain  and  cannot  be  confidently  reckoned  on. 

TREATMENT. — The  condition  is  excessively  difficult  to  get  rid  of, 
and,  as  far  as  our  present  knowledge  goes,  it  can  neither  be  prevented  nor 
can  its  occurrence  be  anticipated.  When  it  is  seen  that  it  is  about  to 
occur — i.e.  when  the  scar  shows  signs  of  thickening — an  attempt  maybe 
made  to  diminish  the  vascularity  of  the  part  by  pressure,  exerted  by 
strapping,  by  the  application  of  collodion,  or  by  a  firm  bandage.  A 
very  simple  method  is  to  paint  the  scar  with  ordinary  (not  flexile)  collodion; 
this  contracts  as  it  dries,  and  diminishes  the  blood-supply  of  the  scar  by 
compressing  the  small  vessels.  This  method  may  be  of  value  in  the 
early  stage,  but  is  not  likely  to  do  good  when  the  cheloid  condition  is  well 
developed.  In  applying  pressure  of  any  kind  it  should  be  borne  in  mind 
that  ulceration  is  apt  to  occur  in  large  cheloids,  and  its  onset  may  eveu 
be  sometimes  precipitated  by  the  application  of  collodion. 

X-ray  treatment  of  cheloid  sometimes  yields  excellent  results, 
but  the  sittings  necessary  to  obtain  this  are  numerous  and  the  treatment 
is  consequently  tedious  and  expensive. 

Fibrolysin  (thiosinamin  salicylate)  is  now  extensively  used,  2-3  c.c. 
of  the  solution  prepared  by  Merck  being  injected  intramuscularly  once 
or  twice  a  week.  This  method  has  drawbacks ;  it  is  slightly  painful, 
and  local  indurated  swellings,  lasting  for  several  weeks,  often  appear  at 
the  site  of  injection.  Its  use  has  been  followed  by  rashes,  and  one  case 
at  least  of  fatal  purpura  has  been  reported.  Against  this  it  must  be 
remembered  that  the  drug  has  been  in  use  for  several  years  and  the 
cases  in  which  unpleasant  or  dangerous  symptoms  have  followed  are 
very  few.  It  is  possible  that  it  should  only  be  used  in  young  subjects. 

Cod  liver  oil  (3J-iv)  or  one  of  its  emulsions  should  be  administered 
about  four  tunes  a  day.  Scarification  of  the  scar  with  a  lancet  or  a  fine 
electric  cautery  point  has  been  practised,  but  it  is  doubtful  whether  any 
permanent  benefit  results  from  this. 

The  question  of  the  advisability  of  excising  a  cheloid  constantly 
arises  and  has  been  much  debated ;  the  great  objection  to  excision  is 
that  the  scar  and  the  stitch  marks  resulting  from  it  will  almost  certainly 
become  cheloid  in  its  turn.  When  a  considerable  area  of  skin  has  been 
excised,  and  there  is  so  much  tension  on  the  stitches  that  they  cut  their 
way  through  the  skin  for  some  distance,  a  very  unsightly  appearance  is 
presented  should  they  become  cheloid.  At  the  same  time  it  seems 
justifiable  to  remove  the  mass  in  certain  cases  even  at  the  risk  of  linear 
cheloid  subsequently  resulting.  For  example,  it  is  well  to  excise  a  broad 
ulcerating  cheloid  which  gives  rise  to  much  contraction  and  great  incon- 
venience, provided  that  the  skin  around  is  sufficiently  lax  to  allow  the 
edges  to  come  together  without  marked  tension  after  they  have  been 
undermined  ;  the  old  broad  scar  is  thus  converted  into  a  linear  one. 
Owing  to  the  tendency  of  the  stitch  marks  to  become  cheloid,  after  an 


206  AFFECTIONS   OF  CICATRICES 

operation  of  this  kind  it  is  advisable  to  avoid  the  use  of  skin  sutures 
entirely  if  that  be  possible  ;  buried  sutures  (see  p.  137)  should  be  em- 
ployed, deep  catgut  stitches  being  inserted,  through  the  subcutaneous 
tissue  only,  from  the  points  where  the  undermining  ceases  on  the  one 
side  to  the  corresponding  points  on  the  other,  so  as  to  relieve  the  tension 
on  the  skin  edges,  which  are  then  approximated  by  stitches  passing 
through  the  fat  and  the  deeper  parts  of  the  skin,  the  actual  margins  being 
brought  together  by  strips  of  gauze  fixed  on  with  collodion.  A  narrow 
cicatrix  is  thus  obtained,  and  it  is  not  a  matter  of  great  importance 
should  this  become  cheloid  ;  sometimes  the  condition  does  not  recur. 
When  a  large  raw  surface  is  left,  it  is  better  not  to  attempt  to  approximate 
the  edges  with  sutures,  but  to  skin-graft  the  entire  wound  instead  (see 
p.  54).  If  this  be  done  it  will  sometimes  happen  that  there  is  no 
recurrence  of  the  cheloid. 

CONTRACTING  CICATRIX. 

This  may  be  a  very  serious  condition  under  certain  circumstances. 
Even  cicatrices  resulting  from  healing  by  first  intention  sometimes 
contract  so  much  as  to  cause  a  good  deal  of  interference  with  movement. 
This  is  well  seen  when  a  thyroid  tumour  has  been  excised  by  a  median 
vertical  incision  ;  if  the  cicatrix  contracts  to  any  extent,  a  band  is 
formed  between  the  sternum  and  the  larynx  which  interferes  with  exten- 
sion of  the  head  upon  the  trunk  and  often  causes  much  inconvenience. 

TREATMENT. — The  cicatrix  can  often  be  divided  transversely 
about  its  centre,  the  skin  and  cicatricial  tissue  undermined,  and  the  divided 
ends  of  the  scar  pulled  well  asunder.  It  is  then  generally  possible  to 
bring  together  the  lateral  angles  of  the  lozenge-shaped  incision  thus  pro- 
duced and  so  convert  the  transverse  into  a  longitudinal  wound,  which 
is  then  stitched  up  and  the  scar  thus  elongated.  When  the  surgeon  has 
to  do  with  a  large  cicatrix,  as  after  burns,  all  tense  bands  should  be  divided 
in  this  manner,  and  the  raw  surface  left  after  separation  of  the  ends  of 
the  cicatrix  grafted  at  once ;  owing  to  the  extent  of  the  affected 
area  it  will  not  be  possible  to  suture  it  in  the  manner  just  described, 
Other  methods  of  dealing  with  the  deformities  caused  by  cicatrices  in 
special  situations  are  discussed  under  their  proper  headings. 

PAINFUL   CICATRIX. 

Cicatrices  are  sometimes  intensely  tender,  so  that  the  slightest  touch 
causes  exquisite  neuralgic  pain  which  radiates  from  the  scar.  These 
painful  scars  occur  most  commonly  when  the  edges  of  a  wound  have  not 
been  brought  together  accurately,  but  they  may  be  met  with  even  after 
healing  by  first  intention  ;  they  indicate  the  implication  of  nerves  in  the 
contracting  scar-tissue. 


ADHERENT  CICATRIX  207 

TREATMENT. — The  only  satisfactory  treatment  is  to  dissect  out 
the  scar,  cutting  well  into  the  healthy  tissues  at  the  sides,  so  as  to  remove 
not  only  the  entangled  nerve  ends  which  may  have  already  become 
bulbous,  but  also  the  adjacent  and  probably  inflamed  portions.  When 
there  is  a  broad  scar  and  the  edges  of  the  wound  cannot  be  brought 
together  after  excision,  skin-grafting  (see  p.  54)  or  some  suitable  plastic 
operation  is  indicated. 


ADHERENT  CICATRIX. 

A  scar  may  be  adherent  to  the  tissues  beneath,  and  may  thus  become 
a  source  of  great  trouble  to  the  patient ;  besides  which,  these  scars  are 
often  weak  and  ulcerate  readily.  For  example,  the  scar  resulting  from 
a  sore  over  the  tibia  may  become  fixed  to  the  bone,  and  is  then  liable  to 
undergo  ulceration  after  injuries  which  would  not  affect  it  were  it  freely 
movable.  The  same  is  also  the  case  with  scars  over  the  ends  of  bones 
after  amputation  ;  should  they  become  adherent  to  the  bone,  the  dis- 
comfort and  pain  they  cause  is  extreme,  and  it  is  therefore  one  of  the 
essentials  of  a  good  stump  that  the  scar  should  not  be  adherent  to  the 
end  of  the  bone. 

TREATMENT. — In  cases  of  adherent  cicatrix  after  amputation,  the 
obvious  remedy  is  to  open  up  the  flaps,  release  the  adhesions,  and  remove 
a  slice  of  the  bone,  if  necessary.  When  an  ordinary  scar  is  adherent  to 
such  structures  as  bones,  tendons,  or  muscles,  an  attempt  may  be  made 
to  divide  it  with  a  tenotomy  knife  introduced  through  the  skin  at  the 
margin  of  the  scar.  Generally,  however,  it  is  best  to  dissect  out  the 
scar  altogether,  and  then  to  turn  in  a  flap  from  the  side  so  as  to  cover 
the  raw  surface  thus  made ;  the  surface  from  which  the  flap  is  taken 
may  be  skin-grafted  (see  p.  54)  if  its  edges  cannot  be  brought  together. 
This  is  preferable  to  grafting  directly  over  bone,  to  which  the  grafts 
might  in  their  turn  become  adherent.  In  some  of  these  cases  it  has  been 
suggested  that  sections  of  the  underlying  bone  should  be  removed,  so  as 
to  shorten  the  limb  and  relieve  the  tension  on  the  wound  left  after  ex- 
cision of  the  scar,  so  that  its  edges  can  be  brought  together.  Although 
this  operation  has  been  practised  more  than  once,  it  can  only  be  called 
for  in  extreme  cases  ;  the  method  just  described  will  suffice  for  the 
majority. 

EPITHELIOMA. 

Scars  which  form  adhesions  to  the  deeper  parts,  or  which  are  con- 
stantly in  a  state  of  irritation,  are  very  apt  to  become  the  seat  of  malignant 
growths,  more  particularly  epithelioma,  as  the  patient  gets  older.  Perhaps 
the  most  common  seats  of  epitheliomata  in  the  extremities  are  an  old 


208  AFFECTIONS    OF  CICATRICES 

adherent  scar,  the  orifice  of  a  sinus,  etc. ;  and  this  is  a  point  which  should 
be  borne  in  mind  in  treating  these  conditions. 

TREATMENT. — The  treatment  of  epithelionm  affecting  scars  is  the 
same  as  the  treatment  of  the  disease  elsewhere — namely,  free  excision  of 
the  diseased  area  and  examination  and,  if  necessary,  excision  of  the 
nearest  lymphatic  glands.  The  exact  nature  of  the  operation  will  depend 
upon  the  situation  and  extent  of  the  disease,  but  there  should  be  no  hesita- 
tion in  removing  it  freely,  even  by  amputation  if  necessary.  Recurrence 
is  less  frequent  after  operation  for  epithelioma  of  the  extremities  than 
for  epithelioma  elsewhere,  and  this  is  partly  due  to  the  fact  that  there 
is  plenty  of  room  for  wide  removal  of  the  disease. 


DIVISION    III. 


CHAPTER    XL 
SYPHILIS. 

SYPHILIS  is  an  infective  disease  due  to  an  organism  discovered  by 
Schaudinn  and  named  by  him  the  Spirochaeta  pallida.  The  disease 
may  be  acquired,  usually  as  the  result  of  impure  sexual  connection,  or 
it  may  be  contracted  in  utero ;  in  the  latter  case  it  is  called  congenital. 

ACQUIRED  SYPHILIS. 

Although  syphilis  is  generally  a  venereal  disease,  extra-genital  infection 
is  well  known,  and  may  take  place  from  direct  contact  with  an  infectious 
person  or  from  some  article  which  has  been  used  by  him.  Syphilis  is 
peculiar  in  that  the  manifestations  of  the  disease  vary  with  the  lapse 
of  time  after  infection,  and  hence  it  is  usually  described  as  having  three 
stages.  This  division  is  convenient  clinically,  though  there  are  theoretical 
objections  to  it.  The  disease  has  a  distinct  tendency  to  subside,  especially 
under  appropriate  treatment.  The  earlier  lesions  are  localised,  superficial, 
symmetrical,  and  highly  infectious,  and  are  accompanied  by  constitutional 
symptoms,  such  as  anaemia  and  often  slight  pyrexia  at  night.  The  later 
lesions  are  erratic  in  their  distribution,  and  are  less  infectious,  but  may 
produce  severe  loss  of  tissue. 

Primary  Stage. — The  first  manifestation  of  acquired  syphilis  appears 
as  an  induration  at  the  seat  of  inoculation,  commonly  termed  a  '  hard  ' 
or  '  Hunterian '  chancre,  which  generally  undergoes  ulceration.  This 
i.  209  p 


210  SYPHILIS 

induration  arises  at  any  time  from  ten  days  to  eight  weeks  after  infection  ; 
it  most  commonly  occurs  about  the  fourth  week.  It  is  followed  by 
enlargement,  first,  of  the  nearest  lymphatic  glands,  and  subsequently  of 
those  in  other  parts  of  the  body.  The  induration  at  the  seat  of  inoculation 
and  the  enlargement  of  the  nearest  lymphatic  glands  are  the  phenomena 
usually  included  under  the  term  '  Primary  Syphilis.'  In  the  male  the 
chancre  is  usually  situated  in  the  fold  between  the  prepuce  and  the 
glans,  but  may  occur  on  either  of  these  structures,  on  the  frenum  or  even 
in  the  meatus.  In  the  female  it  is  most  commonly  inside  the  labia,  and 
when  small,  the  patient  may  be  unaware  of  its  existence.  Extra-genital 
chancres  are  by  no  means  uncommon.  They  occur  on  the  lip,  eyelid, 
tongue,  tonsil,  rectum,  and  cervix  uteri ;  surgeons  and  obstetricians  are 
liable  to  contract  the  disease  when  examining  infected  patients,  and  in 
them  the  sore  is  usually  situated  at  the  side  of  the  finger-nail. 

Syphilitic  infection  frequently  co-exists  with  that  of  gonorrhoea, 
chancroid,  or  both.  The  presence  of  a  soft  sore  often  obscures  the  early 
diagnosis  of  syphilis,  and  these  cases  should  always  be  kept  under  obser- 
vation until  the  absence  of  induration  and  of  secondary  symptoms  nega- 
tives the  diagnosis  of  syphilis.  In  these  cases  serum  diagnosis  by  the 
Wassermann  reaction  (see  Appendix)  is  specially  valuable,  and  the 
presence  or  absence  of  spirochsetae  in  the  deeper  parts  of  the  chancre  of 
course  clinches  the  diagnosis.  As  regards  the  Wassermann  reaction,  it 
must  be  noted  that  it  does  not  appear  until  some  days,  or  even  three  or 
four  weeks,  have  elapsed  since  the  appearance  of  the  sore.  The  primary 
chancre  varies  from  a  slight  parchment-like  induration,  sometimes  very 
difficult  to  recognise,  to  a  deep  sloughing  ulceration  or  phagedenic 
chancre  causing  extensive  loss  of  tissue.  The  severity  of  the  disease 
corresponds  to  a  certain  extent  to  the  severity  of  the  primary  sore. 

Secondary  Stage. — Following  the  primary  condition,  and  usually 
commencing  within  three  months  after  infection,  a  series  of  inflammatory 
phenomena  occurs  which  affect  the  skin,  mucous  membranes,  fibrous 
tissues,  periosteum,  etc.,  and  these  phenomena  appear  at  intervals  and 
are  spread  over  a  period  of  time,  the  length  of  which  varies  with  the 
severity  of  the  attack,  but  which  lasts  about  two  years  on  the  average. 

The  onset  of  the  secondary  stage  is  marked  by  the  appearance  of 
general  glandular  enlargement.  The  glands  are  hard,  rounded,  and 
discrete  ;  there  is  probably  no  specific  liability  of  one  set  of  glands  to 
enlargement  more  than  another,  but  the  presence  of  enlarged  supra- 
trochlear  or  sub-occipital  glands  without  any  obvious  cause  is  always  sug- 
gestive of  syphilis.  The  early  phenomena  are  usually  the  mildest  and  the 
most  superficial,  but  the  lesions  become  of  a  severer  type  and  are  more 
deeply  seated  as  time  goes  on.  During  this  period,  which  is  spoken  of  as 
that  of '  Secondary  Syphilis,'  are  seen  such  affections  as  erythematous, 
papular,  squamous,  pustular,  and  nodular  syphilides  on  the  skin,  and 
mucous  patches  or  condylomata  on  the  skin  or  mucous  membranes.  There 


ACQUIRED  SYPHILIS  211 

is  also  frequently  alopecia,  due  either  to  simple  malnutrition  of  the  hair 
caused  by  syphilis,  or  resulting  from  pustular  syphilides  of  the  scalp  ;  in 
the  former  case  it  is  temporary,  the  hair  growing  again  as  the  patient  re- 
covers ;  in  the  latter,  the  loss  of  hair  may  be  permanent.  Periostitis  may 
also  occur,  and  may  lead  to  permanent  bony  formations  or  nodes  if  it  be 
left  untreated.  Iritis  and  other  rarer  affections  are  also  met  with  in  the 
secondary  period.  During  the  course  of  syphilis  the  general  health  is 
often  markedly  affected,  especially  during  the  early  secondary  period, 
when  the  patient  becomes  pale,  weak,  and  cachectic,  and  the  red  blood 
corpuscles  are  diminished  in  number  and  lose  a  considerable  proportion 
of  their  haemoglobin.  At  this  stage  too  there  is  often  marked  pyrexia. 

Tertiary  Stage. — Following  the  secondary  stage  come  the  pheno- 
mena spoken  of  as  lesions  of  '  Tertiary  Syphilis  '  ;  these  may  follow 
immediately  upon  those  of  the  secondary  stage,  or  they  may  occur 
before  the  latter  reaches  its  termination.  Usually,  however,  they  do 
not  appear  until  a  considerable  interval  has  elapsed,  the  patient  having 
enjoyed  many  years  of  apparently  perfect  health  in  the  meantime. 
They  usually  take  the  form  of  gummata  or  fibrosis  in  the  various  tissues 
and  organs,  or  obstinate  ulcerations  of  the  skin  or  mucous  membranes. 

In  the  later  stages  of  syphilis  numerous  affections  of  the  central 
nervous  system  occur.  These  have  been  termed  parasyphilitic  lesions, 
as  they  are  not  accompanied  with  the  formation  of  definite  gummata. 
Locomotor  ataxia  and  general  paralysis  of  the  insane  are  generally  held 
to  be  of  this  nature. 

TREATMENT. — From  the  point  of  view  of  prophylaxis  it  is  well  to 
enumerate  some  of  the  chief  sources  and  modes  of  contagion  of  syphilis  ; 
the  prophylaxis  will  obviously  consist  in  avoiding  them.  The  most 
common  source  of  infection  is  perhaps  the  secretion  from  the  primary 
sore,  but  a  potent  factor  in  the  spread  of  the  disease  is  the  discharge  from 
secondary  lesions,  such  as  mucous  patches  and  condylomata ;  the  blood 
also  is  infective  during  the  secondary  stage,  and  this  infectivity  is  at  its 
height  when  syphilitic  manifestations  are  actually  present.  The  usual 
mode  of  contagion  is  by  sexual  connection,  but  kissing  is  also  a  means  of 
spreading  the  disease  when  secondary  symptoms  are  present  in  the  mouth 
or  throat ;  in  suckling  also,  infection  may  be  conveyed  from  child  to 
nurse  or  vice  versa.  Simple  sores  on  the  fingers  of  medical  men  may  also 
become  inoculated ;  in  the  Jewish  rite  of  circumcision  infection  has  also 
occurred.  Infection  may  be  conveyed  by  vaccination,  should  the  blood  of 
a  syphilitic  infant  contaminate  the  vaccine  lymph ;  lastly,  the  disease 
may  be  communicated  through  the  medium  of  infected  utensils,  such  as 
cups,  spoons,  pipes,  toys,  etc.,  which  have  been  used  by  those  suffering 
from  secondary  syphilis. 

When  a  person  has  been  exposed  to  the  risk  of  having  the  organisms 
deposited  upon  any  part  of  the  body,  a  careful  disinfection  of  the  area  with 

a  mercurial  lotion  should  be  carried  out,  followed  by  the  application  of  a 

p  2 


212  SYPHILIS 

calomel  ointment  (25  to  50  percent.).  When  a  medical  man  is  examining 
a  case  suspected  to  be  syphilitic,  the  risk  of  infection  can  be  minimised  by 
wearing  thin  rubber  gloves  or  by  laying  a  square  of  gutta-percha  tissue 
over  the  sore  or  ulcer  that  it  is  desired  to  examine,  and  palpating  through 
that. 

The  treatment  of  the  various  lesions  in  the  different  tissues  and 
organs,  in  so  far  as  they  call  for  special  treatment,  will  be  found  in  connec- 
tion with  affections  of  the  particular  organ  or  tissue.  Here  we  shall  only 
refer  to  the  treatment  of  syphilis  in  general. 

At  the  present  time  the  whole  question  of  the  treatment  of  syphilis  is 
under  revision.  If  what  Ehrlich  hopes  from  the  use  of  his  new  drug 
'  Salvarsan  '  or  '  606  '  be  obtained,  the  treatment  of  syphilis  by  mercury 
and  iodide  of  potassium  will  fall  largely,  if  not  entirely,  into  disuse. 
We  have,  however,  thought  it  best  to  let  these  methods  stand  since  the 
new  compound  has  been  only  introduced  so  recently  that  a  reliable  and 
full  judgment  as  to  its  merits  cannot  yet  be  formed.  The  immediate 
results  that  follow  its  use  in  all  stages  of  the  disease  are  most  remarkable, 
but  already  several  syphilographers  are  throwing  grave  doubts  upon  its 
efficacy  ;  whether  it  be  as  a  result  of  an  insufficient  dose,  or  of  faulty 
administration,  or  from  some  other  cause,  some  surgeons  seem  already 
to  have  had  recurrences.  All  that  we  have  seen  so  far  has  been  most 
favourable  to  the  drug,  but  longer  time  must  be  allowed  to  elapse  before 
we  can  venture  to  give  a  definite  opinion  upon  the  many  points  involved 
in  its  use. 

Our  colleague,  Dr.  W.  D'Este  Emery,  Pathologist  to  King's  College 
Hospital,  whose  experience  in  the  administration  of  the  drug  is  consider- 
able, has  been  good  enough  to  furnish  us  with  the  subjoined  account  of 
the  technique  of  the  procedure. 

The  Treatment  of  Syphilis  by  'Salvarsan'  ('606').— The 
latest  method  for  the  treatment  of  syphilis  consists  in  the  use 
of  an  organic  compound  of  arsenic,  dioxydiamidoarsenobenzol,  usually 
known  by  its  trade-name  of  '  Salvarsan,'  or  more  familiarly  as  '  606.' 
This  was  introduced  by  Ehrlich  after  an  exhaustive  research  into  the 
action  of  many  organic  compounds  of  arsenic  on  animals  infected  with 
parasitic  protozoa.  It  was  hoped  that  it  would  act  by  destroying  all  the 
parasites  in  the  body,  effecting  what  Ehrlich  terms  the  '  therapia  magna 
sterilisans.'  At  the  tune  of  writing  it  is  not  quite  certain  whether  this 
can  be  effected  in  all,  or  in  a  large  proportion  of  cases — or  how  permanent 
the  cures  which  it  effects  may  be — but  we  have  sufficient  knowledge  of 
its  action  to  recognise  it  as  the  most  potent  therapeutic  agent  at  our 
disposal.  Its  action  is  extremely  rapid,  and  it  often  effects  in  a  few  days 
an  amount  of  benefit  which  could  only  be  hoped  for  after  some  weeks  of 
careful  mercurial  treatment.  Given  with  proper  precautions  in  suitably 
selected  cases,  it  appears  to  be  devoid  of  any  serious  injurious  effects.  It 
is  at  present  thought  to  be  contra-indicated  in  elderly  patients,  and  in 


ACQUIRED   SYPHILIS  213 

patients  suffering  from  advanced  and  serious  internal  organic  disease, 
if  not  syphilitic  in  origin  ;  in  cases  in  which  the  fundus  oculi  is  not  normal ; 
and  especially,  perhaps,  in  patients  with  advanced  vascular  degeneration. 
It  should  be  said,  however,  that  these  precautions  may  be  found  in  the 
future  to  err  on  the  side  of  caution,  and  patients  suffering  from  all  of 
these  conditions  have  been  treated  with  the  drug  without  mishap. 

'  Salvarsan '  is  a  yellowish  powder  which  is  sold  in  glass  bulbs  exhausted 
of  air  and  hermetically  sealed.  It  dissolves  in  water  or  in  normal  saline 
solution,  yielding  a  clear  yellow  solution  which  is  highly  acid  in  reaction. 

Several  methods  of  administering  the  substance  are  in  vogue,  of  which 
the  pleasantest  for  the  patient  and  the  most  rapidly  efficacious  is  the 
intravenous  ;  it  is,  however,  perhaps  a  little  the  most  difficult  in  applica- 
tion. The  simplest  method  is  that  of  Volk,  who  gives  the  powder  freshly 
ground  up  with  liquid  paraffin  and  injects  it  under  the  skin  of  the  back. 
This  probably  allows  a  more  continuous  action  of  the  substance  to  occur, 
and  may  be  used  with  advantage  after  an  intravenous  injection.  Another 
method  is  that  of  Herxheimer,  who  triturates  the  powder  with  one-third 
of  a  cubic  centimetre  of  20  per  cent,  caustic  soda,  adds  gradually  10  c.c.  of 
distilled  water,  continuing  to  grind  the  whole  together,  and  injects  imme- 
diately. This  is  injected  deeply  into  the  muscle  of  the  buttock.  It  is 
an  effectual  process,  but  is  often  so  painful  that  it  is  not  advisable  to 
use  it,  if  any  other  can  be  used. 

Numerous  forms  of  apparatus  have  been  introduced  for  use  in  the 
intravenous  method.  The  ordinary  infusion  used  for  saline  infusions  is 
supposed  not  to  be  sufficient,  since  some  method  is  required  by  which  no 
trace  of  the  solution  shall  be  injected  into  the  tissues.  To  avoid  this  it  is 
usual  to  employ  a  two-way  canula  by  which  normal  saline  solution  can  be 
injected  first,  then  the  solution,  and,  lastly,  normal  saline  again.  But  if 
the  technique  here  described  be  followed,  no  special  apparatus  is  required 
and  an  ordinary  infuser  will  answer  very  well.  The  author  uses  an  appa- 
ratus (see  Fig.  58)  which  presents  the  advantages  of  being  cheap  and 
portable,  of  being  easily  sterilised,  and  of  allowing  the  solution  to  be 
filtered  through  a  sterile  filter-paper  just  before  use.  It  consists  of  a 
glass  bottle  of,  at  least,  400  c.c.  capacity  (a),  fitted  as  awash-bottle,  and 
having  a  funnel  (b) ,  the  stem  of  which  almost  touches  the  bottom  of  the 
bottle,  and  a  short  tube  passing  just  through  the  bung  (c) .  To  this  is  fitted 
about  a  yard  of  india-rubber  tubing  (d),  which  fits  into  a  short  length  of 
glass  tubing  (e),  which  serves  as  a  window.  To  this  a  needle  (g),  about  as 
large  as  those  used  for  antitoxin,  or  a  little  larger,  is  fitted  by  another 
short  length  of  india-rubber  tubing  (/).  A  second  bottle  (k)  of  about  the 
same  capacity  as  the  first  is  also  required  ;  it  should  be  plugged  with 
cotton  wool  and  should  contain  a  few  glass  beads.  To  prepare  the 
apparatus  for  use.  300  c.c.  of  normal  saline  solution  made  with  distilled 
water  (this  is  important)  are  placed  in  the  bottle  (a),  and  both  it  and  the 
other  bottle  are  sterilised  in  the  autoclave  ;  a  filter-paper  must  first  be 


214 


SYPHILIS 


placed  in  the  funnel  (b},  and  it  is  advisable  to  protect  it  against 
subsequent  infection  by  tying  over  it  a  sheet  of  cotton-wool.  This  is 
not  to  be  removed  until  the  apparatus  is  at  the  bedside.  The  solution 
must  in  all  cases,  be  prepared  fresh. 

The  process  is  as  follows :  First,  pour  about  30-40  c.c.  of  saline  solution 
from  bottle  a  to  bottle  k.  Add  the  whole  of  the  contents  of  one  bulb  of 
the  drug  (o-6  gram),  and  shake  it  gently  until  solution  is  complete  ;  take 
care  that  none  of  the  powder  cakes  on  to  the  side  of  the  bottle  and  escapes 
solution.  This  is  less  likely  to  occur  if  the  glass  balls  be  used,  though 


FIG.  58. — APPARATUS  FOR  THE  INTRA-VENOUS  INJECTION  OF  '  SALVARSAN.' 
The  technique  is  fully  explained  in  the  text. 

they  are  not  absolutely  necessary.  Now  add  cautiously  from  a  hypo- 
dermic needle  enough  of  a  15  per  cent,  solution  of  caustic  soda  to  precipitate 
the  substance  and  to  re-dissolve  it,  again  forming  a  clear  yellow  solution  ; 
the  amount  required  is  about  20  minims.  Then  pour  the  whole  of  the 
fluid  remaining  in  bottle  a  to  bottle  k,  and  mix  the  two  fluids.  Lastly, 
filter  the  whole  through  the  filter  in  the  funnel  b  into  the  bottle  a. 

While  the  filtration  is  taking  place,  sterilise  the  skin  of  the  antecubital 
fossa  and  apply  a  narrow  bandage  around  the  upper  arm,  so  as  to  make 
the  veins  below  it  as  prominent  as  possible,  just  as  in  the  operation  of 
venesection. 

Filtration  being  complete,  remove  the  filter-paper,  and  invert  the 
bottle.  The  fluid  will  run  down  the  tube  d,  and  when  it  appears  in  the 


ACQUIRED   SYPHILIS 


215 


needle,  the  flow  must  be  stopped  by  applying  a  clip  or  a  pair  of  Spencer 
Wells's  forceps  to  the  short  length  of  india-rubber  tubing  (^) .  It  is  impor- 
tant to  make  sure  that  all  air  has  been  got  out  of  the  tube,  and  that  no 
solution  remains  in  the  point  of  the  needle. 

Push  the  point  of  the  needle  through  the  patient's  skin  about  a 


Fro.  59. — IMTRA-VENOUS  INFUSION  OF  '  SALVARSAN.'  A  shows  the  bottle  lowered  so  as  to 
produce  a  negative  pressure  in  the  needle,  while  in  B  it  is  raised  so  as  to  force  the  fluid  into 
the  vein. 

quarter  of  an  inch  from  the  vein,  and  pointing  upwards,  and,  when  the 
bevel  is  completely  buried,  get  the  assistant  who  is  holding  the  bottle 
to  lower  it,  so  as  to  bring  it  below  the  point  where  the  needle  has  entered 
the  skin  (see  Fig.  59,  A).  This  creates  a  negative  pressure  in  the  needle, 
and  when  the  latter  is  pushed  onwards  and  enters  the  vein,  blood 
immediately  enters.  This  is  recognised  by  watching  the  glass  tube  (e) ,  and 
as  soon  as  blood  is  seen  in  this  the  ligature  must  be  loosed  from  the  upper 
arm,  and  the  bottle  raised  (see  Fig.  59,  B).  The  solution  will  now  begin 


216  SYPHILIS 

to  flow  into  the  vein,  pushing  the  blood  before  it,  and  the  process  is 
allowed  to  go  on  until  the  desired  amount  is  injected.  (It  is  an  advantage 
to  have  the  bottle  a  marked  in  divisions  of  50  c.c.  ;  if  this  be  done  and  if  the 
bulb-full  of  the  drug  has  been  dissolved  in  300  c.c.  of  normal  saline  solution 
as  recommended,  each  division  will  correspond  to  O'i  gram  of  the  powder.) 
When  the  requisite  amount  of  the  solution  has  run  in,  the  bottle  is 
again  lowered  until  blood  appears  in  the  tube  e.  The  needle  is  then  slid 
quickly  out  of  the  vein,  and  an  antiseptic  pad  applied  for  a  few  hours. 
The  whole  process  should  not  take  more  than  a  quarter  of  an  hour, 
exclusive  of  the  preparation  of  the  solution. 

If  an  ordinary  transfusion  apparatus  be  used,  the  same  device  of 
lowering  and  raising  the  vessel  will  serve  to  avoid  the  injection  of  the 
solution  into  the  tissues. 

The  operation  is  often  followed  by  nausea  and  vomiting  (which  may 
usually  be  controlled  by  a  mustard  leaf  to  the  epigastrium),  diarrhoea, 
a  temperature  of  101°  F.  or  more,  and  occasionally  by  pallor  and  syncope. 
In  many  cases,  however,  no  untoward  effects  are  seen,  and  in  any  case 
they  are  of  short  duration.  There  should  be  no  local  trouble  if  the 
injection  be  properly  given. 

In  stout  patients  without  prominent  veins  it  may  be  necessary  to 
expose  the  vein  by  dissection. 

The  doses  usually  recommended  are  o '5  gram  for  a  male  adult,  0-4  fora 
female.  The  dose  for  a  child  is  much  smaller,  certainly  not  more  than 
3  centigrams  ;  and  it  is  advisable,  first,  to  treat  the  mother  with  the 
substance,  and  allow  the  child  to  take  her  milk,  which  has  been  found 
by  Ehrlich  and  others  to  have  a  remarkable  beneficent  action. 

When  treated  with  an  intravenous  injection  in  this  way,  especially 
if  followed  up  by  a  second  in  a  day  or  two,  or  by  an  intramuscular  injec- 
tion, or  by  both,  a  chancre  should  heal  up  in  ten  days  at  most,  sometimes 
in  much  less,  and  other  syphilitic  manifestations  in  a  proportionate  time. 
There  should  be  abundant  evidence  of  improvement  in  two  or  three  days. 
Very  often  there  is  a  local  inflammatory  reaction  around  the  lesions, 
recalling  a  tuberculin  reaction  ;  such  cases  usually  do  well. 

The  Treatment  of  Syphilis  by  Mercury  and  the  Iodides. — Unlike 
the  foregoing  method,  the  treatment  by  these  drugs  varies  according 
to  the  stage  in  which  the  affection  is  when  treatment  is  begun,  and, 
therefore,  we  shall  discuss  it  in  relation  to  the  three  clinical  stages  of 
the  disease — namely,  primary,  secondary,  and  tertiary  syphilis.  It  is 
interesting  to  note  that,  although  the  division  between  secondary  and 
tertiary  syphilis  is  somewhat  arbitrary,  more  particularly  in  respect 
to  the  time-limit,  a  further  justification  for  this  division  is  found  in 
the  fact  that  the  two  drugs  which  exercise  a  specific  influence  on  the 
disease — namely,  mercurial  preparations  and  the  iodides  of  potassium 
and  sodium — act  differently  in  the  two  stages.  During  the  early  secondary 
stage  the  iodides  have  little  or  no  effect  in  causing  the  disappearance 


ACQUIRED  SYPHILIS  217 

of  the  lesions,  while  mercury  acts  much  more  effectually.  During  the 
tertiary  stage,  on  the  other  hand,  the  iodides  are  much  more  rapid  in 
their  action  than  is  mercury. 

The  Local  Treatment  of  Primary  Syphilis. — In  the  local  treatment 
of  the  sore  irritating  applications  should  be  avoided.  No  attempt 
should  be  made  to  destroy  the  chancre  by  caustics ;  the  application 
of  a  caustic  never  causes  the  disease  to  abort,  and  only  produces 
extension  of  the  ulceration.  Excision  of  chancres  is  also  not  to  be 
recommended  as  a  general  rule.  In  the  great  majority  of  cases  the 
infection  has  spread  far  beyond  the  seat  of  inoculation  by  the  time  the 
diagnosis  can  be  made  with  certainty,  and  there  is  no  chance  of  cutting 
short  the  disease  by  removing  the  sore.  During  the  early  period, 
when  the  diagnosis  is  uncertain,  frequent  washings,  followed  by  the  appli- 
cation of  half-strength  boric  ointment,  or  boric  lint,  should  be  relied 
upon.  The  parts  should  be  kept  as  dry  as  possible  and  rest  insisted  on, 
especially  in  women.  When  the  diagnosis  is  certain,  the  favourite  local 
application  is  lotio  nigra.  The  sore  is  washed  with  this  three  or  four 
times  daily,  after  which  a  piece  of  lint  soaked  in  the  lotion  is  applied 
over  its  surface.  If  the  penis  be  the  part  affected,  it  should  be  kept  in  a 
bag  made  by  sewing  boric  or  salicylic  wool  between  two  layers  of  gauze  ; 
this  prevents  friction  and  avoids  soiling  of  the  linen.  When  the  sore  is 
large  and  extending  it  is  well  to  dust  it  over  with  calomel  and  starch 
(calomel  one  part,  starch  powder  three  parts)  two  or  three  times  a  day, 
after  drying  its  surface ;  when  there  is  sloughing  or  when  the  discharge 
is  offensive,  one  part  of  iodoform  or  iodol  may  be  added  to  this.  Lint 
dipped  in  lotio  nigra  is  then  applied  to  the  surface  of  the  ulcer.  When 
the  chancre  begins  to  heal,  the  local  use  of  mercurials  may  be  given  up 
and  boric  lotion  and  weak  boric  ointment  substituted. 

In  the  acutely  spreading,  so-called  phagedenie  chancre,  it  is  well  to 
bring  the  patient  rapidly  under  the  influence  of  mercury,  especially  if 
the  chancre  be  in  a  situation  where  its  spread  may  do  serious  harm. 
These  so-called  phagedenie  chancres,  although  not  true  phagedena,  are 
nevertheless  often  due  to  a  mixed  infection,  and  the  rule  as  to  the  use  of 
caustics  may  be  relaxed  here.  When  sloughing  progresses  actively  in 
spite  of  the  above  treatment,  the  surface  of  the  sore  should  be  scraped  so 
as  to  remove  all  the  sloughs,  and  then  undiluted  carbolic  acid  applied  to 
the  raw  surface  ;  this  may  be  followed  by  dusting  with  calomel  and 
iodoform,  and  the  internal  administration  of  mercury.  When  the  sore 
is  small,  it  may  be  scraped  with  a  sharp  spoon,  after  application  of  an 
8  per  cent,  solution  of  eucaine  to  its  surface.  If  it  be  large,  a  general 
anaesthetic  will  be  required,  and  the  sore  should  be  clipped  away  with 
scissors  or  destroyed  by  nitric  acid  (see  p.  63) .  Boric  fomentations  are 
then  applied  until  granulation  is  general,  and  before  each  fresh  fomen- 
tation is  put  on  the  sore  should  be  irrigated  with  a  solution  of  peroxide 
of  hydrogen  (10  vols.). 


2i8  SYPHILIS 

At  one  time  the  question  whether  mercury  should  be  given  during  the 
primary  stage  was  much  debated.  The  view  very  widely  held  was  that 
it  was  not  advisable  to  put  the  patient  upon  a  mercurial  course,  since 
the  diagnosis  of  syphilis  at  this  stage  was  seldom  beyond  the  possibility  of  a 
mistake,  and  the  patient  might  thus  be  salivated  or  submitted  to  a  tedious 
and  prolonged  course  of  mercury  unnecessarily.  The  diagnosis  of  the 
disease,  however,  can  now  be  settled  with  certainty  in  some  cases  by 
the  discovery  of  the  spirochseta,  and  with  considerable  probability  in 
others  by  Wassermann's  test  (see  Appendix),  and  this  objection  therefore 
falls  to  the  ground  in  these  cases.  It  may  be  laid  down  as  a  general 
rule  that  mercurial  treatment  should  be  begun  as  soon  as  the  diagnosis 
can  be  made. 

During  the  primary  stage  iron  is  of  great  value  and  may  be  given  as 
Blaud's  pills  (five  to  ten  grains  three  times  daily  immediately  after  food) 
in  capsules  or  cachets.  Cachectic  subjects  should  be  given  a  tonic  such 
as  half  a  drachm  of  Easton's  syrup  three  times  a  day  in  a  wineglassful 
of  water. 

The  General  Treatment  of  Secondary  Syphilis. — The  principal  drug 
employed  in  the  treatment  of  the  secondary  stage  is  mercury,  and  the 
chief  points  to  be  considered  are  in  connection  with  its  administration. 
Whilst  mercury  is  being  taken,  the  following  points  should  be  attended  to : 

(1)  Only  plain  and  nourishing   food   should  be  taken,  indigestible 
matters,  spices,  and  condiments  being  avoided. 

(2)  Alcohol  should  be  given  up,  unless  the  patient  is  accustomed  to 
take  it  regularly,  when  a  small  amount,  of  a  light  claret,  hock,  or  sauterne 
may  be  allowed. 

(3)  Regular  exercise  should  be  taken  ;  but  violent  forms,  such  as 
football,  hunting,  and  the  like,  must  be  avoided,  as  otherwise  greater 
quantities  of  mercury  will  be  required  to  bring  the  patient  properly  under 
its  influence.     It  has  long  been  recognised  that  persons  taking  mercury 
are  prone  to  catarrhs  of  a  severe  type. 

(4)  The  care  of  the  teeth  is  of  the  highest  importance.     If  tartar  be 
allowed  to  accumulate  on  them,  salivation  may  occur  before  the  patient 
is  fully  under  the  influence  of  the  drug,  and  there  may  be  considerable 
difficulty  in  continuing  the  mercury  on  account  of  the  premature  tender- 
ness of  the  gums.     The  teeth  should  be  brushed  frequently  during  the 
day,  and  an  astringent  mouth-wash  containing  alum  and  tincture  of 
myrrh,  or  ten  grains  of  chlorate  of  potash  to  the  ounce  of  water,  may 
be  employed  if  there  be  any  tenderness. 

(5)  Smoking  should  be  prohibited  because  the  irritation  it  gives  rise  to 
predisposes  to  and  keeps  up  throat,  mouth,  and  tongue  affections. 

Modes  of  Administration  of  Mercury. — Mercury  may  be  adminis- 
tered by  the  mouth,  by  the  skin,  and  by  intra-muscular  injection.  Adminis- 
tration by  the  mouth  has  many  advantages,  and  we  recommend  it  for  all 
cases  except  those  in  which  there  is  some  definite  indication  for  its 


ACQUIRED  SYPHILIS  219 

administration  by  other  means.  It  is  simple,  cleanly,  and  painless,  and 
involves  the  minimum  amount  of  trouble  to  both  surgeon  and  patient. 
There  are,  however,  two  groups  of  patients  for  whom  it  is  unsuited — 
namely,  those  who  wish  to  avoid  taking  the  drug  and  those  who  assimilate  it 
from  the  alimentary  canal  either  too  slowly  or  not  at  all.  Therefore  intra- 
muscular injections  are  largely  employed  in  the  public  services,  partly  on 
account  of  the  simplicity  of  the  procedure,  the  accuracy  of  the  dosage  and 
the  consequent  shortening  of  the  course,  but  chiefly  because  the  patient  is 
certain  of  receiving  and  absorbing  the  desired  quantity  of  mercury.  In 
all  cases  in  which  gastro-enteritis  follows  the  administration  of  the 
drug  by  the  mouth  and  in  those  of  very  severe  and  rapid  syphilis  in 
cachectic  subjects,  some  more  rapid  means  of  bringing  the  patient 
under  the  influence  of  the  drug  than  that  obtained  by  oral  adminis- 
tration should  be  adopted.  The  only  drawback  to  administation  by 
the  mouth  in  cases  in  which  it  is  well  borne  is  that  the  course  is 
longer,  on  account  of  the  slower  absorption  of  the  drug  from  the  ali- 
mentary canal. 

Among  the  various  preparations  of  the  drug  administered  by  the  mouth, 
the  metallic  form  acts  best  during  the  early  stages,  and  is  usually  given 
either  in  the  form  of  blue  pill  or  as  a  pill  of  hydrargyrum  cum  creta.  In 
this  stage  also  it  is  well  to  combine  it  with  iron,  and  the  following  is  a 
good  formula : 

B   Pil.  hydrargyri.          .          .          .          .     gr.   i 
Ferri  sulphatis  .          .          .          .  gr.    \ 

Extract,  opii      .          .          .          .          .     gr.     | 

M.     Ft.  pil.     Two  pills  to  be  taken  thrice  daily. 

'  Hutchinson's  formula '  consists  of  hydrarg.  c.  cret.  and  Dover's  powder 
in  equal  quantities  made  up  into  four-grain  pills,  one  of  which  is  taken 
three  times  a  day.  The  amount  of  Dover's  powder  should  be  varied 
according  to  the  action  of  the  mercury  upon  the  bowels.  The  quantity  of 
mercury  may  be  gradually  increased,  so  long  as  no  intestinal  irritation  is 
produced,  until  the  mercury  begins  to  manifest  its  physiological  effects,  as 
shown  by  salivation  or  soreness  of  the  gums.  When  this  stage  is  reached, 
the  dose  should  be  reduced,  or,  if  the  tenderness  of  the  gums  be  extreme, 
the  drug  may  be  discontinued  entirely  for  two  or  three  days  until  the 
tenderness  has  passed  off,  when  it  may  be  resumed  in  smaller  doses.  It 
should  not  be  discontinued  altogether  when  the  physiological  effects 
manifest  themselves  ;  as  a  rule  the  secondary  phenomena  do  not  disappear 
until  the  physiological  action  of  the  mercury  is  apparent.  This  method 
is  the  one  we  prefer  to  use  if  possible. 

The  accompanying  table,  taken  from  the  Manual  of  Venereal  Diseases, 
by  the  officers  of  the  R.A.M.C.,  indicates  the  methods  adopted  in  the 
army  for  the  treatment  of  syphilis.  Any  course  is,  however,  liable  to 
necessary  variations,  and  must  not  be  adhered  to  too  strictly.  The 


220 


SYPHILIS 


table  gives,  however,  an  excellent  guide  to  the  amount  of  mercury 
necessary  in  an  average  case. 


Treatment  by  i  gr.  Hg  Pills 

Months 

Pills 

Grs.  Hg 

First  Course. 

i  month,  taking  6  pills  a  day          .... 

I 

1  80 

60 

3  days'  rest            ....... 

— 

— 

— 

i  month,  taking  4  pills  a  day           .... 

I 

I2O 

40 

7  days'  rest            ....... 

— 



— 

i  month,  taking  3  pills  a  day           .... 

I 

QO 

30 

i  month's  rest       ....... 

I 



— 

Second  Course. 

3  months,  taking  3  pills  a  day         .... 

3 

270 

90 

i  month's  rest       ....... 

i 



— 

Third  Course. 

3  months,  taking  2  pills  a  day        .          . 

3 

1  80 

60 

Interval  of  i  month       ...... 

i 



— 

Fourth  Course. 

3  months,  taking  i  pill  a  day           .... 

3 

90 

30 

3  months'  rest       ....... 

3 



— 

Fifth  Course. 

3  months,  taking  i  pill  a  day          .... 

3 

90 

3° 

Total 

21 

1,020 

34° 

Thus  the  course  lasts  a  little  more  than  twenty-one  months,  during 
which  time  the  patient  takes  340  grains  of  mercury. 

At  a  later  stage  of  secondary  syphilis  in  weakly  subjects  other  forms 
of  mercury  often  act  better,  and  give  rise  to  less  intestinal  irritation  than 
the  one  just  described.  The  green  iodide  of  mercury,  for  example,  may 
be  given  in  pill  form,  in  doses  of  a  quarter  to  half  a  grain  combined  with 
a  quarter  of  a  grain  of  extract  of  opium,  three  or  four  times  a  day.  In 
the  late  secondary  stage,  and  especially  when  the  patient  is  very  anaemic 
and  feeble,  the  French  preparation  known  as  '  Gibert's  syrup '  is  often 
extremely  good.  Each  ounce  of  this  contains  one- twelfth  of  a  grain  of 
biniodide  of  mercury,  five  grains  of  iodide  of  potassium,  syrup,  and  water. 

When  more  rapid  mercurialisation  is  required  in  a  patient  who  will 
carry  out  instructions  faithfully,  it  is  best  to  employ  inunction,  and  in 
the  later  stages  of  the  secondary  period  iodide  of  potassium  should  be 
administered  internally  at  the  same  time.  The  longer  the  syphilis  has 
lasted  the  better  is  the  result  obtained  by  combining  iodide  of  potassium 
with  the  mercury.  The  ointment  usually  selected  for  inunction  is 
unguentum  hydrargyri,  but  better  results  are  obtained  with  a  10  or  20 
per  cent,  oleate  of  mercury  combined  with  an  equal  quantity  of  lanoline  ; 
this  preparation  has  the  advantage  of  not  soiling  the  linen  as  much 
as  the  blue  ointment  generally  does. 


ACQUIRED  SYPHILIS 


221 


Inunction  is  carried  out  as  follows.  A  portion  of  the  unguentum 
hydrargyri  about  the  size  of  a  hazel-nut  is  rubbed  well  into  the  skin  every 
night,  if  possible  before  a  warm  fire,  and  fifteen  or  twenty  minutes  should 
be  occupied  in  doing  this.  The  ointment  may  be  rubbed  into  any  part  of 
the  body  where  the  skin  is  comparatively  thin,  preferably  into  the  axillae 
or  the  groins,  and  the  same  part  should  not  be  used  on  two  successive 
nights,  as  otherwise  considerable  irritation  of  the  skin,  and  possibly  a 
pustular  eruption,  may  be  caused.  For  example,  the  inunction  should 
be  made  into  one  axilla  on  the  first  night,  into  the  other  the  following 
night,  whilst  on  the  third  one  'groin,  and  on  the  fourth  the  other  may 
be  chosen  ;  on  the  fifth  night  inunction  may  be  employed  over  the 
abdomen,  and  the  patient  should  wear  the  same  under-linen  and  should 
not  have  a  bath  during  these  five  days.  At  the  end  of  this  period  he 
should  take  a  warm  bath,  and  then  commence  again,  and  go  on  in  this 
way  until  the  gums  become  tender,  which  will  usually  be  in  about  six  or 
ten  days.  As  soon  as  this  happens,  the  patient  should  have  a  warm 
bath,  put  on  clean  linen,  stop  the  inunction,  and  substitute  for  it  the 
internal  use  of  mercurials,  such  as  two-grain  doses  of  pil.  hydrargyri  com- 
bined with  extract  of  opium,  three  or  four  times  daily  (see  p.  219). 
Should  the  condition  of  the  gums  get  worse  under  this  treatment,  the  dose 
of  pil.  hydrargyri  should  be  reduced  ;  should  it  improve,  the  dose  may  be 
increased  slightly,  and  continued  for  two  or  three  weeks  after  the  eruption 
has  disappeared,  when  it  may  be  reduced  to  one-half  or  one-third  of  the 
amount ;  this  must  be  continued  for  a  considerable  time  (see  p.  220). 

In  the  '  Manual  of  Venereal  Diseases '  the  plan  recommended  is  to 
use  for  each  inunction  ung.  hydrarg.  gr.  xl  and  adeps  lanae  (B.P.)  gr.  xx. 
The  course  of  treatment  is  as  follows ;  the  course  lasts  nearly  two  years 
and  no  less  than  3,280  grains  of  mercury  are  employed  : 


Treatment  by  Inunction 

Months 

Inunctions 

Grs.Hg 

First  Course. 
42  daily  inunctions     ...... 
3  months'  rest  ....••• 

«i 

3 

42 

840 

Second  Course. 
Same  as  first      ....... 

4i 

42 

840 

Third  Course. 
30  daily  inunctions     ....•• 
6  months'  rest   ....••• 

i 
6 

30 

600 

Fourth  Course. 
30  daily  inunctions     ...... 
6  months'  rest   ...•••• 

i 
6 

30 

600 

Fifth  Course. 
20  daily  inunctions     ...-•• 

Total 

1 

20 

400 

231 

164 

3,280 

222  SYPHILIS 

Another  method  of  introducing  mercury  into  the  system  through 
the  skin  is  by  fumigation,  the  drug  employed  being  calomel ;  it  is  best 
performed  at  bedtime.  About  thirty  grains  of  calomel  are  placed  in 
a  small  metal  dish,  which  is  surrounded  by  another  containing  a  little 
boiling  water,  and  the  whole  is  placed  over  a  spirit-lamp.  This  vaporising 
apparatus  is  put  under  the  seat  of  a  cane  chair,  upon  which  the  patient 
divested  of  his  clothes,  sits  surrounded  by  a  blanket  reaching  to  the 
floor,  and  tucked  tightly  round  the  neck  so  as  to  prevent  the  escape 
of  the  calomel  vapour.  It  takes  about  twenty  minutes  for  the  calomel 
to  be  volatilised,  and  the  patient  sits  meanwhile  in  a  profuse  perspira- 
tion, so  that  the  drug  is  readily  absorbed  through  the  skin.  After  the 
sitting,  the  patient  is  wrapped  in  a  blanket  and  goes  to  bed.  Two  baths 
a  week  generally  suffice,  especially  if  the  patient  be  weakly,  but  one  may 
be  given  every  night  should  it  be  necessary  to  get  him  rapidly  under 
the  influence  of  mercury.  This  method  is  useful  for  obstinate  skin 
affections,  but  otherwise  it  is  seldom  employed  ;  the  smell  of  the  vaporis- 
ing calomel  is  very  penetrating  and  offensive. 

The  administration  of  mercury  by  infra-muscular  infections  has  been 
used  largely  of  recent  years.  The  numerous  preparations  of  mercury 
employed  fall  into  two  classes — namely,  (a)  Soluble  salts  of  mercury  ;  of 
these  we  recommend  the  succinamide  of  mercury  in  doses  of  one-fifth  or 
two-fifths  of  a  grain  two  or  three  times  a  week,  (b)  Insoluble  mercurial 
preparations ;  these  may  contain  either  metallic  mercury  or  calomel,  and 
are  best  bought  ready  prepared,  as  their  manufacture  requires  minute  sub- 
division of  the  active  ingredient.  Perhaps  the  best  formula  is  Lambkin's, 
usually  spoken  of  as  '  mercurial  cream.' 

Metallic  mercury          .          .          .          gr.    j 
Creo-camph         ....  grs.  ij 

Palnaitin  basis     .          .         .          .     ad  Tl[   x 

'  Creo-camph  '  is  a  preparation  of  creosote  and  camphoric  acid,  and 
is  added  to  prevent  the  pain  which  otherwise  comes  on  three  or  four 
days  after  the  injection.  The  above  amount  constitutes  a  dose. 

The  preparations  containing  metallic  mercury  are  preferable  to  those 
containing  calomel,  as  the  latter  cause  severe  pain  at  the  site  of  injection 
and  give  rise  to  more  risk  of  local  sepsis. 

Intra-muscular  injections  are  of  great  service  when  it  is  required  to 
obtain  the  physiological  effects  of  mercury  very  rapidly,  or  when  the 
administration  of  mercury  by  the  mouth  leads  to  gastro-intestinal  irrita- 
tion. It  possesses  the  further  advantage  that  the  patient  is  certain  of 
absorbing  the  given  dose  of  mercury,  which  does  not  always  happen 
when  it  is  given  in  other  ways,  since  the  patient  may  either  not  take  it 
at  all  or  may  not  absorb  it  when  taken.  The  soluble  salts  allow  more 
accurate  dosage,  but  the  injections  require  to  be  made  frequently  and  are 
often  painful.  The  insoluble  preparations  yield  admirable  results  and 


ACQUIRED  SYPHILIS 


223 


need  only  be  injected  once  a  week  ;  they  have  the  disadvantage,  however, 
that  a  week's  supply  of  mercury  is  injected  at  one  sitting  and  absorption 
of  the  drug  cannot  be  checked  should  any  mercurialism  manifest  itself. 
The  use  of  such  a  preparation  as  a  routine  in  all  cases  is  therefore  not 
to  be  recommended  ;  it  is  better  to  reserve  it  for  cases  in  which  administra- 
tion of  grey  powder  by  the  mouth  fails,  and  in  which  therefore  there 
can  be  no  abnormal  susceptibility  to  the  drug. 

The  injection  should  be  made  with  rigid  aseptic  precautions,  the 
needle,  which  should  be  of  platino-iridium,  should  be  inserted  deeply 
into  the  substance  of  a  large  muscle,  such  as  the  gluteus  maximus  or 
deltoid,  at  right- angles  to  the  surface,  care  being  taken  to  avoid  large 
nerve-trunks.  The  needle  is  best  sterilised  in  olive  oil,  which  does  not  blunt, 
it  and  at  the  same  time  acts  as  a  lubricant.  Although  the  material  injected 
contains  mercury,  it  must  be  carefully  sterilised  or  there  may  be  trouble- 
some suppuration.  It  is  also  important  to  prevent  the  injection  escaping 
along  the  needle-track  during  and  after  the  injection  ;  if  it  does,  a 
painful  subcutaneous  nodule  will  occur.  The  injection  should  not  be 
begun  until  the  needle  is  well  into  the  muscle,  and  should  then  be  made 
slowly  so  as  to  separate  but  not  rupture  the  muscular  fibres. 

The  following  is  the  plan  of  treatment  followed  at  the  Rochester 
Row  Hospital,  and  gives  a  good  idea  of  an  average  course : 


Injections  of  Metallic  Mercury 

Mouths 

Injections   Grs.  Hg 

First  Course. 

6  injections  (each  weekly)        ..... 

I* 

6 

6 

Interval,  2  months         ...... 

2 

—             — 

Second  Course. 

4  injections  (each  fortnightly)           .... 

2 

4              4 

Interval,  4  months           ...... 

4 



Third  Course. 

Same  as  second     ....... 

6 

4 

4 

Fourth  Course. 

4  injections  (each  fortnightly)          .... 

2 

4 

4 

6  months'  rest       ....... 

6 

— 

— 

Fifth  Course. 

Same  as  fourth     ....... 

2 

4 

4 

Total 

25i 

22 

22 

Each  injection  consists  of  Tl\x  of  the  cream  and  contains  gr.  j  of  metallic 
mercury. 

It  is  possible  that  our  present  ideas  as  to  the  length  of  time  that  is 
required  for  a  course  of  mercurial  treatment  may  undergo  considerable 
alteration  should  the  Wassermann  serum  test  prove  reliable  and  of 


224  SYPHILIS 

general  application,  as  we  shall  then  have  a  definite  means  of  testing 
the  disappearance  of  the  disease. 

The  local  treatment  is  usually  of  considerable  benefit  in  secondary 
syphilis  ;  the  eruptions  seem  to  be  favourably  affected  by  the  local 
application  of  mercury.  Eruptions  on  the  face  often  disappear  quickly 
under  the  use  of  emplastrum  hydrargyri,  the  patient  meanwhile  being 
treated  constitutionally  by  one  of  the  methods  already  described.  The 
plaster  should  be  renewed  every  night ;  it  may  be  employed  usefully 
also  for  skin  eruptions  elsewhere. 

Acid  nitrate  of  mercury  may  also  be  employed.  This  preparation, 
however,  is  a  powerful  caustic  and  must  be  applied  with  care,  but  it  is  a 
valuable  preparation  for  mucous  patches  on  the  throat  and  for  condylo- 
mata,  especially  when  they  are  ulcerating  and  spreading ;  it  should  be 
painted  on  with  a  glass  brush  two  or  three  times  a  week.  Condylomata 
and  mucous  patches  also  disappear  rapidly  when  local  treatment  is  com- 
bined with  the  internal  administration  of  mercury.  They  should  be 
washed  night  and  morning,  dried,  and  dusted  over  with  a  powder  consist- 
ing of  one  part  of  calomel  and  three  parts  of  starch.  Lotio  nigra  makes 
a  valuable  gargle  in  cases  of  syphilis  of  the  mouth  and  throat. 

The  General  Treatment  of  Tertiary  Syphilis. — During  this  stage  the 
lesions  will  be  removed  much  more  rapidly  by  means  of  iodide  of  potassium 
than  by  mercury.  We  usually  begin  with  fifteen  grains  of  the  iodide  of 
potassium  three  times  a  day,  and  if  this  does  not  suffice  to  influence  the 
lesions  rapidly,  the  dose  may  be  increased  up  to  thirty  or  forty  grains. 
The  iodide  should  be  taken  from  half  an  hour  to  an  hour  after  meals, 
and  it  is  well  to  give  it  with  tincture  of  orange  peel  or  syrup  of  cinchona 
in  order  to  avoid  griping.  Some  patients  cannot  take  iodide  of  potassium  ; 
and  if  it  be  administered  they  suffer  severely  from  coryza,  pustular 
eruptions  on  the  skin  and  pains  in  the  bones.  Under  these  circumstances 
the  sodium  or  strontium  salt  may  be  substituted  for  that  of  potassium, 
but  if  these  cannot  be  borne,  resort  must  be  had  to  mercurial  inunction 
or  intra-muscular  injections.  It  is  a  curious  fact  that  patients  suffer 
less  from  the  physiological  action  of  iodide  of  potassium  in  large  than  in 
small  doses,  and,  before  giving  up  the  drug  entirely,  one  or  two  large 
doses  at  any  rate  should  be  tried. 

It  must  be  remembered  that  iodide  of  potassium  only  causes  the 
disappearance  of  the  syphilitic  lesions  and  that  it  has  no  permanent 
curative  effect.  It  is  well,  therefore,  to  give  the  patient  a  mercurial 
course  at  the  same  time  that  he  is  being  treated  with  the  iodide  of 
potassium,  especially  in  syphilis  of  important  organs,  such  as  the  brain, 
the  liver,  etc.  After  the  gums  have  become  affected  the  mercury  may 
be  given  up  for  a  short  time  and  then  continued  in  smaller  doses  just  as 
in  secondary  syphilis  (see  p.  219). 

The  Local  Treatment. — The  local  application  of  mercury,  especially 
in  the  form  of  emplastrum  hydrargyri,  is  often  beneficial  in  the  tertiary 


ACQUIRED  SYPHILIS  225 

period.  In  obstinate  cases,  and  particularly  in  tertiary  bone  lesions, 
much  advantage  may  be  gained  by  excising  and  scraping  away  the 
gummatous  material  in  the  same  way  as  tuberculous  tissue  is  treated, 
but  in  most  instances  the  lesions  rapidly  disappear  when  iodide  of 
potassium  and  mercury  are  administered  simultaneously. 

Sulphur  Baths  and  Spas  have  a  considerable  vogue  in  the  treatment 
of  syphilis,  and  a  visit  to  Aix-la-Chapelle  is  frequently  advised.  These 
waters,  however,  have  no  specific  effect  on  syphilis,  and  the  benefit 
derived  from  a  visit  to  Aix  is  due  to  the  careful  antisyphilitic  treatment 
carried  out  there  and  to  the  fact  that  the  patient  gives  himself  up  entirely 
to  the  treatment.  The  hot  baths  help  the  action  of  the  antisyphilitic 
remedies  to  a  certain  extent,  and  some  of  the  benefit  is  also  due  to  the 
complete  rest  and  absence  of  worry.  A  nervous  overworked  business 
man  with  an  obstinate  syphilitic  affection  may  be  sent  to  Aix,  Wildbad, 
or  some  similar  place  with  advantage,  but  it  would  be  wrong  to  put 
patients  of  moderate  or  limited  means  to  the  expense  of  going  there. 
The  best  time  for  a  visit  to  Aix-la-Chapelle  is  May  or  June,  but  it  is  open 
all  the  year  round. 

An  important  question  is,  how  long  the  mercury  should  be  continued, 
for  there  seems  good  reason  to  believe  that,  in  the  milder  cases  of  syphilis 
at  all  events,  an  actual  cure  may  be  brought  about  by  careful  treatment ; 
at  any  rate  tertiary  symptoms  may  never  supervene.  Everyone  is  agreed 
that  the  mercury  should  be  continued  in  as  large  doses  as  possible 
without  producing  salivation,  at  least  until  the  secondary  symptoms,  for 
which  it  is  administered,  have  subsided,  and  for  two  or  three  weeks 
afterwards.  Also,  that  when  fresh  symptoms  appear,  mercury  should 
be  again  administered  as  before.  It  is  now,  however,  a  generally  accepted 
view  that  the  treatment  with  small  doses  of  mercury  (about  one-third  of 
the  dose  required  to  produce  the  physiological  action)  should  be  per- 
sisted in  after  the  symptoms  have  subsided.  Should  these  recur,  the 
full  dose  is  again  resorted  to.  On  pp.  220-3  we  have  given  tables  showing 
the  periods  for  which  mercury  is  administered  by  the  officers  of  the 
R.A.M.C.  and  the  intervals  between  the  administrations.  These  may 
be  taken  as  fairly  typical  of  the  general  body  of  opinion  as  to  the  duration 
of  the  mercurial  course,  which  it  will  be  seen  from  a  reference  to  these 
tables  is  spread  over  a  period  of  about  two  years.  It  must,  however, 
be  understood  that  the  administration  of  mercury  must  be  continuous 
in  the  first  instance  until  the  physiological  action  is  produced,  and  that  on 
any  subsequent  appearance  of  symptoms  the  dose  must  be  again  raised 
until  the  gums  become  sore. 

It  is  very  difficult  to  say  when  a  patient  can  consider  himself  cured, 
and  it  is  to  be  hoped  that  recent  work  upon  the  serum  diagnosis  will  be 
able  to  afford  a  definite  answer  to  this  question.  Founder  considers  that 
a  patient  may  be  allowed  to  marry  when  he  has  undergone  a  full  course 
of  treatment  (about  two  years),  when  he  has  had  no  symptoms  for  at 
i.  0 


226  SYPHILIS 

least  a  year  and  a  half  subsequent  to  this,  and  when  the  course  of  the 
disease  has  been  mild.  If  experience  bears  out  the  view  that  the  disease 
is  cured  when  the  blood  gives  a  negative  Wassermann  reaction  three 
months  after  the  end  of  a  mercurial  course,  a  great  advance  will  have 
been  made,  and,  should  this  reaction  stand  the  test  of  time,  it  will  be  a 
most  valuable  method  of  checking  the  results  of  a  mercurial  course,  and 
therefore  its  duration. 

HEREDITARY  SYPHILIS. 

When  a  child  with  inherited  syphilis  is  born  alive,  the  lesions  are 
much  the  same  as  the  secondary  and  tertiary  ones  in  the  acquired 
form,  but  they  are  apt  to  be  more  mixed  in  character,  and  tertiary  lesions 
may  occur  quite  early. 

TREATMENT. — The  treatment  of  hereditary  syphilis  is  essentially 
the  same  as  that  of  the  acquired  form — namely,  the  use  of  mercury  in  the 
early  lesions,  and  of  iodide  of  potassium,  with  or  without  mercury,  in 
the  later  forms.  Mercury  is  best  administered  to  infants  by  means  of 
inunction,  as  by  this  means  irritation  of  the  stomach  and  interference 
with  the  feeding  of  the  child  are  entirely  avoided.  One  of  the  most 
convenient  ways  is  to  spread  some  unguentum  hydrargyri  (a  piece  about 
the  size  of  a  small  hazel-nut)  upon  the  binder,  leaving  it  to  the  natural 
wriggling  movements  of  the  child  to  rub  the  mercury  into  the  skin.  The 
binder  is  removed,  the  skin  well  washed,  and  fresh  ointment  applied  daily. 
Should  there  be  any  irritation  of  the  skin,  about  ten  grains  of  a  ten- 
per-cent.  oleate  of  mercury  may  be  rubbed  into  the  legs  and  arms  instead 
of  using  the  abdominal  inunction.  As  soon  as  the  symptoms  begin  to 
improve,  the  quantity  used  should  be  diminished,  but  mercurial  treat- 
ment should  be  gone  on  with,  either  in  the  form  of  mild  inunctions  or 
by  internal  administration,  at  any  rate  for  the  first  year  after  birth.  If 
internal  administration  of  mercury  be  preferred,  one-sixth  of  a  grain  of 
hydrarg.  cum  cret.,  or  one-hundredth  of  a  grain  of  bichloride  of  mercury 
well  diluted  may  be  given  three  or  four  times  a  day.  The  hydrarg.  cum 
cret.  may  usefully  be  combined  with  bicarbonate  of  soda  in  the  propor- 
tion of  one  grain  of  the  former  to  five  of  the  latter ;  one  grain  of  this 
is  given  three  or  four  times  a  day  to  an  infant.  The  bichloride  of 
mercury  may  be  given  in  the  form  of  liq.  hydrarg.  perchlor.  flavoured 
with  aq.  anethi  or  aq.  chloroformi.  At  the  same  time  it  is  of  great 
importance  to  attend  to  the  proper  feeding  of  the  child. 

In  prescribing  iodide  of  potassium,  the  dose  will  vary  with  the  child's 
age.  Sir  Lauder  Brunton's  plan  of  calculating  the  dose  for  different 
ages  is  very  simple  and  efficacious.  He  takes  the  age  for  the  full  adult 
dose  as  twenty-five,  and  reckons  the  age  of  the  child  at  its  next  birth- 
day as  an  integral  part  of  that  number  ;  the  full  adult  age  is  used  as  the 
denominator,  and  the  child's  age  thus  reckoned  is  used  as  the  numerator. 


HEREDITARY  SYPHILIS  227 

Thus,  the  dose  for  a  child  in  the  first  year  of  life  would  be  one-twenty- 
fifth  of  the  adult  dose,  that  for  a  child  one  year  old,  two-twenty-fifths 
of  the  adult  dose,  and  so  on.  When  the  syphilis  has  not  appeared,  or 
at  any  rate  has  not  been  treated  with  mercury,  in  infancy,  it  is  well  to 
employ  mercurial  inunction  in  addition  to  the  iodide  of  potassium  which 
will  be  required  in  the  later  manifestations  of  the  disease. 

'  Salvarsan '  in  its  application  to  this  form  of  the  disease  has  been 
referred  to  above  by  Dr.  Emery  (see  p.  216). 


CHAPTER    XlL 
TUBERCULOSIS. 

TUBERCULOSIS  is  an  infective  disease,  due  to  the  growth  of  the 
tubercle  bacillus  in  the  tissues.  The  affection  is  characterised  by  the 
formation  of  nodules  or  tubercles  tending  to  run  together,  break  down 
and  caseate,  and  to  destroy  the  structures  in  which  they  are  situated. 

SEATS. — The  most  frequent  seat  of  tuberculosis  is,  perhaps,  the 
lymphatic  glands,  more  particularly  those  of  the  cervical,  bronchial,  and 
mesenteric  regions.  Another  common  seat  of  the  affection  is  the  peri- 
osteum, and  the  cancellous  tissue  at  the  ends  of  bones.  Tuberculous 
lesions  are  frequently  met  with  in  the  synovial  and  serous  mem- 
branes ;  they  may  also  occur  in  various  internal  organs,  such  as  the 
lungs,  the  kidneys,  the  prostate,  etc.  In  fact,  a  tuberculous  lesion  may 
occur  wherever  there  is  connective  tissue  and  a  suitable  spot  for  the 
growth  of  the  bacillus  after  it  has  gained  access  to  the  body. 

ACCESSORY  FACTORS.  —  Although  the  tubercle  bacillus  is 
the  essential  cause  of  tuberculosis,  a  number  of  accessory  factors  are  con- 
cerned in  the  production  of  the  disease ;  without  their  concurrence  the 
affection  often  would  not  occur.  These  accessory  causes  may  be  local 
or  general. 

Local. — Among  local  factors  injury  plays  an  important  part  as 
a  predisposing  and,  sometimes,  as  an  exciting  cause  of  the  tuberculous 
lesions ;  this  is  most  frequently  the  case  in  tuberculosis  of  bones  and 
joints.  It  is  important  to  note  that  the  injury  must  be  a  mild  one ;  a 
severe  one,  such  as  a  fracture,  does  not  usually  lead  to  the  deposit  of 
tubercle  in  the  damaged  part,  probably  because  the  processes  of  repair 
are  then  so  active  that  the  bacillus  cannot  cope  with  them.  A  slight 
injury,  on  the  other  hand,  particularly  one  in  the  nature  of  a  sprain, 
weakens  the  tissues  without  leading  to  any  marked  cell-exudation,  and 
the  bacilli  then  seem  able  to  obtain  a  good  footing  in  them.  Exposure 
to  cold  probably  also  acts  in  this  way,  and,  when  the  bacilli  are  already 
present  in  the  body,  it  leads  to  their  deposit  in  the  part  subjected  to  the 

228 


ACCESSORY    FACTORS  229 

action  of  the  cold.  Indeed,  anything  which  lowers  the  vitality  and 
resistance  of  the  tissues  predisposes  them  to  the  attack  of  the  tubercle 
bacillus. 

Sepsis  is  also  important,  not  so  much  as  an  inducing  cause  as  one 
which  increases  the  activity  of  the  disease,  or  at  any  rate  interferes  with 
its  spontaneous  cure.  Chronic  inflammation  of  a  tissue  seems  to.  weaken 
it  and  to  enable  the  bacilli  to  obtain  a  foothold  and  to  spread  more  rapidly 
than  in  healthy  parts,  and  anything  which  keeps  up  a  state  of  chronic 
inflammation  may  favour  the  development  of  tubercle  in  persons  in  whose 
bodies  the  bacilli  are  present. 

There  are  also  certain  conditions  connected  with  the  bacilli  themselves 
which  are  of  great  importance,  the  principal  being  the  number  of  the 
organisms  that  gain  access  to  the  part.  When  the  bacilli  are  few  in 
number  the  risk  of  infection  is  not  great,  and  if  it  does  occur,  the  disease 
is  generally  more  chronic  than  when  they  are  numerous.  The  bacilli  also 
vary  in  virulence  under  different  conditions;  and,  lastly,  the  result 
depends  a  good  deal  upon  whether  they  are  free  or  are  attached  to  coarser 
particles.  When  bacilli  are  isolated  and  are  present  only  in  small 
numbers  they  sometimes  pass  through  the  mucous  membranes  and  become, 
caught  in  the  neighbouring  lymphatic  glands  without  giving  rise  to  any 
primary  disease  at  the  seat  of  entrance  ;  this  is  more  especially  the  case: 
in  the  intestinal  tract  and  the  lungs.  When,  however,  they  are  attached' 
to  coarser  particles,  as,  for  example,  when  the  source  from  which  the 
infection  is  derived  is  cheesy  material  which  is  not  broken  up  very  fine, 
then  there  is  a  local  tuberculosis  at  the  point  of  entrance,  from  which 
glandular  infection  may  result. 

General. — The  question  of  heredity  is  one  of  the  first  for  consider- 
ation, and  it  is  held  by  many  that  tuberculosis  is  an  hereditary  disease- 
As  a  matter  of  fact,  however,  there  is  no  evidence  of  true  heredity  ;  what 
seems  to  be  inherited  is  only  the  tendency  of  the  tissues  to  form  a  good 
nidus  for  the  growth  of  the  tubercle  bacillus.  This  tendency  may  also 
be  induced  by  such  conditions  as  bad  hygiene,  confinement  in  close  rooms, 
foul  air,  etc.  ;  according  to  others,  the  same  result  is  produced  by  the 
ingestion  of  foods  rich  in  potash  and  deficient  in  sodium,  such  as  an 
excessive  amount  of  vegetables,  especially  potatoes. 

Age  and  sex  appear  to  exercise  an  important  influence  on  the  develop- 
ment of  tuberculosis,  although  we  cannot  exactly  say  in  what  way  the 
influence  is  exerted.  Surgical  tuberculous  diseases  are  most  frequent 
in  children  before  the  age  of  ten,  but  they  also  occur  up  to  old  age ;  and 
it  is  important  to  note  that,  the  older  the  patient  is,  the  less  is  the  likeli- 
hood of  a  spontaneous  cure.  Sex  has  also  a  considerable  influence  in  so 
far  that  females  do  not  seem  to  be  so  predisposed  to  certain  forms  of 
tuberculosis  as  are  males.  This  applies  more  particularly  to  the  affections 
of  bones  and  joints;  and  although  this  may  be  explained  to  some  extent 
by  the  greater  exposure  of  the  male  to  injury,  this  consideration  does 


230  TUBERCULOSIS 

not  entirely  meet  the  facts.  Climatic  conditions  are  important  accessory 
factors.  When  individuals  are  exposed  to  cold  and  wet,  and  when, 
moreover,  they  congregate  in  small  over-heated  rooms,  the  disease  is 
very  apt  to  occur,  especially  if  one  of  the  community  has  tuberculosis 
and  thus  forms  a  focus  of  infection  for  the  rest. 

PATHOLOGY. — When  introduced  into  the  tissues,  the  bacillus 
leads  to  the  formation  of  a  collection  of  cells,  termed  a  tubercle.  This  is  a 
collection  of  densely  packed  lymphocytes  surrounding  a  central  mass  of 
cells  termed  epithelioid  cells,  which  are  much  larger  than  the  ordinary 
lymphocyte,  and  are  probably  derived  from  pre-existing  connective-tissue 
cells,  from  the  lymphatic  endothelium,  or  even  sometimes  from  the  endo- 
thelium  of  the  blood-vessels.  Among  these  epithelioid  cells  one  or  more 
giant  cells  are  formed,  probably  by  the  imperfect  division  of  epithelioid 
cells,  the  nuclei  dividing  and  separating,  but  the  protoplasm  remaining 
undivided.  The  tubercles  increase  in  number  until  a  large  mass  is 
formed  ;  caseation  then  commences  in  the  older  tubercles,  the  cells 
gradually  die,  and  a  cheesy  material  is  formed  in  the  centre,  or  at  any  rate 
in  the  older  part  of  the  mass  ;  this  may  become  encapsuled  and  remain 
quiescent,  or  it  may  give  rise  to  a  chronic  abscess.  There  is  generally  a 
considerable  area  around  the  tubercles  which  is  not  yet  infected  with  the 
bacillus,  but  which  is  in  a  state  of  chronic  inflammation  ;  this  rhronic 
inflammation  is  of  great  importance  in  favouring  the  spread  of  the  tubercle 
bacillus,  which  invades  any  structure  thus  affected  more  readily  than  one 
that  is  quite  healthy. 

Retrogressive  Changes. — The  resistance  of  the  living  tissues  to 
the  growth  of  the  organism  is  considerable,  so  that  when  the  causes  which 
facilitate  the  progress  of  the  disease  are  removed,  the  bacillus  may  be 
destroyed  or  gradually  cease  to  grow.  Retrogressive  changes  then  take 
place,  consisting  essentially  in  the  conversion  of  the  tubercle  into  fibrous 
tissue  and  the  ultimate  disappearance  of  the  tuberculous  material.  When 
the  tuberculous  tissue  has  undergone  caseation,  however,  and  recovery 
takes  place,  portions  of  the  cheesy  material  are  absorbed,  whilst  others 
are  left  behind  and  become  encapsuled  or  calcified  and  quiescent  for  the 
time  being.  Unfortunately  the  bacilli  or  their  spores  retain  their  vitality 
in  these  masses  for  an  indefinite  period  ;  as  long  as  the  capsule  around 
the  caseous  material  is  unbroken,  and  the  latter  is  protected  from  the 
action  of  the  cells  and  juices  of  the  tissues,  the  bacilli  seem  to  lie  dormant, 
but  any  slight  injury  or  some  constitutional  cause  may  break  up 
the  encapsuled  mass  and  lead  to  fresh  growth  of  the  organism  and  fresh 
infection  of  the  part.  It  is  very  important  to  remember  that,  when  the 
conditions  are  favourable,  the  body  has  a  very  strong  tendency  to  check 
the  growth  of  the  bacillus  or  even  to  overcome  it  altogether. 

Various  causes  prevent  the  living  tissues  from  destroying  the  tubercle, 
and  these  influences  must  be  borne  in  mind  so  that,  if  present,  they  may 
be  neutralised  or  removed.  The  majority  of  them  have  already  been 


TREATMENT  231 

mentioned  ;  they  are  the  conditions  of  the  tissues  which  facilitate  the 
growth  of  the  bacilli,  such  as  those  produced  by  heredity  or  induced  by 
food  ;  attention  to  diet  is  therefore  an  important  point  in  treatment. 
Injuries  not  only  predispose  the  tissues  to  the  deposit  of  tubercles  in  the 
damaged  part,  but  are  also  likely  to  increase  the  virulence  of  the  disease 
when  present.  Cold  or  sepsis  acts  similarly,  while  the  influence  of  climate 
and  hygienic  conditions  is  great.  The  relation  of  tuberculosis  to  other 
diseases  is  also  of  interest,  for  the  occurrence  of  the  latter  in  tuberculous 
patients  is  apt  to  light  up  the  disease  or  to  encourage  its  spread.  This 
is  especially  the  case  with  regard  to  influenza,  measles,  and  chicken-pox, 
and  therefore  exposure  to  these  diseases  should  be  avoided  as  far  as 
possible. 

TREATMENT.— Only  the  General  Treatment  of  tuberculosis 
will  be  dealt  with  here  ;  the  local  treatment  must  be  considered  in  connec- 
tion with  the  parts  affected,  and  is  described  in  speaking  of  the  various 
structures  in  which  it  may  arise.  The  general  treatment  of  tuberculous 
disease  has  two  chief  amis — viz.  to  place  the  body  in  a  better  con- 
dition to  resist  the  progress  of  the  disease,  and  to  act  directly  upon 
the  tuberculous  process.  The  methods  of  treatment  directed  to  the  latter 
end  consist  essentially  of  various  forms  of  operations,  and  the  use  of 
various  substances  supposed  to  favour  the  destruction  of  the  tubercle 
bacillus — for  example,  Koch's  tuberculin  or  one  of  its  modifications, 
iodoform,  benzoate  of  soda,  and  many  others.  The  dosage  and  methods 
of  administration  of  tuberculin  are  dealt  with  by  Dr.  Emery  (see 
Appendix). 

There  are  various  methods  of  general  treatment  designed  to 
increase  the  resisting  power  of  the  tissues,  or  to  remove  the  causes 
favouring  the  growth  of  the  bacillus,  which  may  be  indicated  here.  An 
essential  point  is  to  put  the  patient  under  the  best  possible  hygienic 
conditions.  A  tuberculous  subject  must  be  kept  from  exposure  to  cold 
and  wet,  which  may  not  only  induce  tuberculosis  in  some  part  of  the 
body  not  yet  affected,  but  may  also  exaggerate  a  lesion  already  existing. 
He  must  have  the  maximum  amount  of  fresh  air  and  sunshine  possible,  and 
therefore  it  is  important  that  he  should  live  a  healthy  outdoor  life.  There 
is,  however,  no  special  climate  suitable  for  all  tuberculous  cases.  Some  do 
better  in  a  cold  and  bracing  climate,  others  in  a  warm  one,  provided  it 
be  not  relaxing.  Hence  all  patients  should  not  be  sent  to  the  same  place, 
or  to  the  same  sort  of  climate  ;  it  is  necessary  to  ascertain  which  suits  the 
individual  best.  The  only  sine  qua,  non  is  that  it  should  be  possible  to 
be  out  of  doors  at  the  place  selected  practically  all  day  without  danger  of 
taking  cold.  The  patient  should  in  fact  lead  the  '  open-air  life  '  that  is 
so  much  in  favour  in  the  sanatorium  treatment  of  tuberculous  disease  of 
the  lung.  When  the  lower  extremities  are  unaffected,  sufficient  exercise 
must  be  taken,  but  it  must  be  of  such  a  character  that  the  patient  runs  no 
risk  of  injury,  for  a  local  deposit  of  tubercle  is  likely  to  occur  at  any  spot 


232  TUBERCULOSIS 

injured.  The  only  point  of  importance  with  regard  to  drugs  is  that  only 
those  should  be  ordered  which  will  increase  the  nutrition  of  the  body.  Of 
these  the  best  seems  to  be  cod  liver  oil,  which  may  be  given  pure  or  as  one 
of  the  many  emulsions  upon  the  market.  As  much  of  the  drug  should  be 
given  as  is  possible  without  disordering  the  digestion.  It  is  well  to  begin 
with  teaspoonful  doses  three  or  four  times  a  day,  and  to  increase  it  until 
the  patient  cannot  bear  any  more  ;  the  oil  should  be  given,  however 
well-nourished  or  healthy  the  patient  may  appear.  As  a  rule,  children 
take  the  emulsions  well.  When  pure  cod  liver  oil  is  used  it  is  probably 
best  to  float  it  on  milk.  Cod  liver  oil  may  be  administered  to  children 
who  resent  taking  the  oil  as  ordinarily  prescribed,  by  replacing  the  oil  in 
which  sardines  are  preserved  by  a  tasteless  variety  of  cod  liver  oil  and 
serving  it  on  the  plate  with  the  fish.  The  tin  is  filled  up  from  time  to 
time  with  the  oil,  and  children  who  are  fond  of  sardines  will  often  take 
large  quantities  of  the  oil  in  this  manner  without  demur.  The  drug  is 
apt  to  disagree  during  warm  weather,  and  it  should  be  intermitted  during 
the  summer ;  useful  substitutes  are  large  quantities  of  cream  (given  in 
tea,  with  junket,  or  with  stewed  fruit),  fat  bacon  or  ham  for  breakfast, 
and  salads  dressed  with  an  abundance  of  olive  oil. 

A  very  popular  drug  in  tuberculosis  is  syrup  of  the  iodide  of  iron,  in 
doses  of  fifteen  to  twenty-five  minims  three  times  a  day,  mixed  with 
water  or  milk,  but  it  is  questionable  whether  it  does  any  good.  Among 
other  drugs,  iron  is  of  value,  either  as  tincture  of  perchloride  of  iron  in 
ten-  or  fifteen-minim  doses,  or  as  Blaud's  preparation  in  doses  of  from 
three  to  ten  grains,  according  to  the  age  of  the  patient.  Tincture  of  nux 
vomica  is  useful  when  the  appetite  is  bad  ;  in  fact,  any  drug  that  will 
increase  the  general  nutrition  of  the  patient  may  be  administered  with 
advantage.  Guaiacol  in  doses  of  one  to  five  minims  is  much  in  vogue  at 
the  present  time,  and  seems  to  be  of  some  service. 

When  exercise  cannot  be  obtained,  as  may  happen  when  the  situation 
of  the  disease  demands  absolute  rest  in  bed,  benefit  may  be  obtained 
by  general  massage.  This,  for  example,  may  be  usefully  applied  to  the 
extremities  when  the  spine  is  the  seat  of  the  disease,  or  to  the  upper 
extremities  or  the  trunk  when  the  lower  limbs  are  affected,  and  in  this 
way  a  substitute  for  exercise  can  be  obtained.  By  these  means  both 
the  appetite  and  the  general  nutrition  can  be  well  sustained.  Efforts 
must  also  be  made  to  diminish  the  inflammation  about  the  affected  area, 
and  the  tendency  to  cure  is  greatly  strengthened  if  these  be  successful. 
The  first  essential  in  this  part  of  the  treatment  is  absolute  rest,  for,  apart 
from  the  presence  of  the  tuberculous  disease,  movement  promotes  the 
inflammatory  condition.  Sometimes,  as  in  joint-disease  (see  Vol.  III.), 
the  pressure  of  the  inflamed  articular  surfaces  against  each  other  due  to 
the  tonic  contraction  of  the  muscles  around  the  diseased  joint  keeps  up 
the  inflammation,  and  therefore  rest  must  be  combined  with  extension, 
so  as  to  relax  the  muscles. 


CHRONIC  ABSCESS  233 

Various  other  methods  may  be  employed  to  remove  the  chronic  inflam- 
mation ;  the  actual  cautery  (see  p.  20)  is  of  value  in  many  cases  of  deep- 
seated  bone  and  joint  disease  ;  pressure  is  also  of  use  and  may  be  employed 
in  combination  with  counter-irritation,  as  by  Scott's  dressing  (see  p.  23), 
or  alone,  by  wrapping  the  joint  in  a  large  mass  of  wool  and  then  applying 
a  firm  bandage  over  it.  The  various  measures  for  combating  chronic 
inflammation  are  fully  described  in  Chapter  I. 


CHRONIC    ABSCESS. 

A  chronic  abscess  is  usually  tuberculous  in  nature ;  in  it  an  abscess 
forms  without  any  of  the  cardinal  symptoms  of  inflammation  except  the 
swelling,  pain  is  absent  or  very  slight,  there  is  not  necessarily  any  pyrexia, 
though  the  affected  area  may  feel  warmer  than  the  surrounding  parts, 
and  there  is  no  redness  of  the  skin  over  the  seat  of  the  disease,  unless  the 
skin  itself  be  involved.  The  swelling  is  caused  by  the  presence  of  fluid, 
and  differs  entirely  from  the  brawny  swelling  that  is  met  with  in  acute 
abscesses. 

A  chronic  subcutaneous  abscess  begins  as  a  small  tuberculous  nodule 
which  gradually  increases  in  size,  undergoes  caseation,  and  softens  in  the 
centre.  When  this  occurs,  the  inflammation  around  becomes  a  little 
more  active,  and  there  is  an  effusion  of  fluid,  along  with  a  considerable 
number  of  white  blood  corpuscles,  mainly  lymphocytes,  into  the  cheesy 
material ;  the  result  being  an  investing  layer  of  tuberculous  tissue 
containing  fluid  mixed  with  broken-down  cheesy  material,  disintegrated 
tissue,  and  lymphocytes.  The  essential  part  of  a  chronic  abscess  is  its 
wall,  and  to  this  any  curative  treatment  must  be  particularly  directed. 
This  wall  consists  of  two  distinct  strata — an  inner  of  soft  granulation-tissue 
which  can  be  readily  scraped  away  with  a  sharp  spoon,  and  an  outer 
fibrous  layer  which  can  only  be  removed  with  a  knife  or  scissors.  There 
is  no  sharp  line  of  demarcation  between  these  two  layers,  and  the  outer 
one  often  merges  into  the  surrounding  tissue.  The  mere  evacuation  of  the 
contents  of  a  chronic  abscess  will  not  necessarily  lead  to  a  subsidence  of 
the  disease,  as  it  does  in  an  acute  one.  The  tubercle  bacilli  and  the 
tubercles  themselves  are  present  in  the  abscess  wall,  and  all  that  is  evacu- 
ated when  the  abscess  is  incised  is  broken-down  caseous  material,  along 
with  the  fluid  and  leucocytes  that  have  passed  into  it  as  the  result  of  the 
inflammation  around.  Even  if  the  abscess  be  curetted,  the  disease  may 
not  be  removed  entirely,  as  there  are  bacilli  in  the  dense  fibrous  layer 
of  the  wall  which  remains  behind. 

TREATMENT. — The  treatment  must  be  directed  to  the  wall  of  the 
abscess,  and  this  is  done  in  various  ways. 

Excision. — When  the  abscess  is  small  and  subcutaneous,  the  simplest 
plan  is  to  excise  it  with  its  contents  intact,  as  if  it  were  a  sebaceous 
cyst.  Similarly,  when  the  abscess  is  connected  with  a  gland,  and  even 


234  TUBERCULOSIS 

when  it  has  perforated  the  gland  capsule  and  spread  through  the  fascia  to 
the  subcutaneous  tissue,  the  only  satisfactory  treatment  is  to  dissect 
out  the  wall  of  the  abscess  and  the  affected  gland  along  with  it. 
To  dissect  away  completely  and  cleanly  the  abscess  wall  and  the  focus 
from  which  it  originates  may  be  regarded  as  the  ideal  treatment  of  a 
chronic  abscess.  If  the  abscess  has  thinned  and  infected  the  skin,  the 
affected  portion  of  the  skin  should  be  removed  also,  as  any  attempt  to 
save  it  will  leave  tuberculous  material  behind,  which  may  act  as  a  focus 
for  re-infection  of  the  wound,  so  that  healing  may  be  delayed ;  if 
left,  the  thinned  skin  will  die  and  an  ugly  scar  will  result.  Hence  all 
adherent  skin  should  be  excised,  and  the  edges  of  the  wound  brought 
together  after  undermining  the  skin  around  ;  the  wound  is  then  stitched 
up  completely  and  treated  as  an  aseptic  incised  wound  (see  p.  133). 
Should  the  abscess  burst  during  the  dissection,  and  pus  escape,  the 
wound  should  be  thoroughly  douched  out  ;  tuberculous  infection  of  the 
wound  rarely  occurs  under  these  circumstances.  When  the  abscess  is 
connected  with  a  gland,  it  is  not  sufficient  to  remove  only  the  gland 
that  has  led  to  the  abscess  ;  any  others  in  the  neighbourhood  that  are 
enlarged  should  also  be  taken  away. 

Partial  Removal  of  the  Abscess  Wall. — In  large  deep-seated  chronic 
abscesses  it  is  impossible  to  remove  the  wall  completely.  Here  the 
surgeon  has  the  choice  of  two  procedures.  If  the  abscess  be  situated  so 
deeply  that  it  cannot  be  dissected  away,  and  if  no  important  structures 
intervene  between  its  wall  and  the  surface,  the  former  should  be  laid 
open  freely  (unless  it  be  important  to  avoid  causing  a  scar),  so  that  the 
whole  interior  of  the  abscess  cavity  is  exposed  to  view  ;  as  much  of  the 
wall  as  possible  should  then  be  dissected  out  and  clipped  away  with 
scissors.  Any  portions  that  cannot  be  treated  in  this  manner  must  be 
thoroughly  scraped.  The  best  instrument  to  use  for  this  purpose  is 
Barker's  flushing  spoon  (see  Fig.  52),  by  means  of  which  a  stream  of 
fluid  is  kept  constantly  flowing  over  the  parts,  so  that  the  material 
loosened  by  the  spoon  is  carried  away  at  once  and  does  not  lodge  in  the 
recesses  of  the  wound.  The  fluid  used  for  this  irrigation  should  be 
i  in  4000  perchloride  of  mercury.  When  the  abscess  cavity  has  been 
thoroughly  scraped  and  cleansed  from  all  flakes  of  cheesy  material  and 
pus,  two  or  three  drachms  of  an  iodoform  and  glycerine  emulsion  i  should 
be  poured  into  the  wound  according  to  the  size  of  the  abscess  ;  the  object 
is  to  employ  enough  of  the  emulsion  to  come  into  contact  with  the  whole 
of  the  scraped  abscess  wall.  The  wound  is  then  stitched  up  and, 
wherever  it  is  possible,  pressure  is  applied  so  as  to  bring  the  deeper 
parts  together  and  to  avoid  leaving  a  cavity.  In  many  cases  the 
wound  heals  by  first  intention  when  treated  in  this  way  and  there  is  no 
further  trouble. 

1  The  emulsion  is  made  by  adding  10  parts  of  iodoform  to  90  parts  of  glycerine 
which  contains  ^oW**1  Part  °*  corrosive  sublimate. 


CHRONIC    ABSCESS 


235 


Incision  and  Scraping. — Another  method  must  be  employed  when  the 
parts  in  front  of  the  abscess  wall  prevent  it  from  being  laid  freely  open,  as, 
for  example,  in  the  case  of  a  psoas  abscess,  or  when  it  is  essential  to  avoid 
a  large  scar.  In  such  cases  it  is  usual  to  make  a  small  opening  sufficient 
to  admit  the  ringer,  or  the  finger  and  a  sharp  spoon,  and  then  to  wash  out 
the  contents  of  the  abscess  with  sterilised  salt  solution  by  means  of 
Barker's  flushing  spoon.  The  opening  in  the  skin  must  be  large  enough 
to  allow  of  the  free  escape  of  the  fluid  by  the  side  of  the  spoon,  which  is 
pushed  into  all  the  recesses  of  the  abscess,  and  is  used  for  scraping  the 
wall  when  all  the  fluid  part  has  been  evacuated.  The  whole  of  the  wall 
is  scraped  gently  but  systematically.  Special  care  should  be  taken  to 
use  the  instrument  very  gently  in  any  direction  in  which  important 
fragile  structures  such  as  the  peritoneum  or  large  veins  are  likely  to  be 
encountered.  After  the  spoon  is  withdrawn,  the  cavity  is  wiped  out 
with  fragments  of  rough  sponge.  Pieces  as  large  as  can  be  forced  into  the 
cavity  are  used  ;  they  not  only  soak  up  any  of  the  flushing  solution  which 
remains,  but  their  rough  surface  scrapes  off  any  tags  of  cheesy  material 
which  still  adhere,  and  so  completes  the  cleansing  of  the  cavity.  About 
half  an  ounce  of  the  iodoform  and  glycerine  emulsion  is  then  injected, 
and  the  skin  wound  is  closed  by  sutures,  which  also  include  the  opening 
through  the  fascia.  The  use  of  the  iodoform  emulsion  is  not  essential, 
as  some  cases  seem  to  do  as  well  without  it ;  on  the  whole,  however, 
better  results  seem  to  follow  when  it  is  employed. 

The  skin  incision  usually  heals  by  first  intention,  and  in  a  certain 
number  of  cases  no  re-accumulation  takes  place.  Sometimes,  however, 
it  is  found  that  deep-seated  fluctuation  is  present  after  a  few  weeks ;  and 
this  is  not  remarkable,  since  the  actual  cause  of  the  abscess — namely,  the 
bone  disease — is  but  seldom  accessible  to  radical  treatment  (i.e.  the  re- 
moval of  the  primary  focus).  When  accumulation  takes  place,  and  is 
found  to  be  increasing,  a  fresh  incision  should  be  made  into  the  sac  and 
the  fluid  again  evacuated.  The  sac  will  be  much  smaller  than  it  was 
originally,  and  the  fluid  of  a  brown  serous  character  containing  iodine 
and  iodoform.  The  sac  wall  should  again  be  scraped,  flushed  out,  and 
injected  with  iodoform  and  glycerine  as  at  the  first  operation.  In  many 
cases  two  operations  suffice  to  cure  even  a  large  abscess  of  this  kind.  In 
some,  however,  three  or  even  more  are  requisite,  but  in  the  majority 
of  cases  the  patient  can  be  got  well  in  this  way  much  more  quickly  and 
much  more  certainly  than  by  the  old  plan  of  draining  the  abscess.  Some- 
times the  wound  gives  way  after  healing  by  first  intention  and  a  small 
sinus  forms  in  the  scar.  Should  this  happen,  the  wound  must  be  opened 
up,  scraped  out  thoroughly  and  stitched  up  as  before,  after  the  sinus  has 
been  dissected  out.  Unless  this  be  done,  the  sinus  may  take  as  long  to 
heal  as  it  did  when  the  old  plan  of  simple  drainage  was  employed.  Even 
should  a  sinus  form  again,  the  same  procedure  should  be  repeated. 

The  old  plan  of  aspiration  of  an  abscess,  which  was  in  common  use 


236  TUBERCULOSIS 

before  Lister  commenced  his  work,  has  been  revived  of  late  years,  and 
though  not  so  efficient  as  the  method  just  described,  possesses  the  advan- 
tage that  there  is  less  risk  of  sepsis  in  the  hands  of  those  unskilled  in 
aseptic  treatment.  The  skin  is  purified  in  the  usual  way  and  a  sterilised 
aspirating  needle  is  thrust  through  it  at  some  distance  from  the  abscess 
and  pushed  on  until  it  enters  its  cavity,  when  the  fluid  is  gradually 
withdrawn.  The  needle  should  not  be  thrust  through  the  most  dependent 
part  of  the  abscess,  and  it  is  important  to  prevent  any  of  the  contents 
finding  their  way  into  the  needle-track,  lest  a  sinus  should  form.  With 
this  object  in  view,  the  piston  of  the  aspirating  syringe  should  be  steadily 
withdrawn  as  the  needle  is  pulled  out. 

Only  the  fluid  part  of  the  contents  of  the  abscess  cavity  can  be  with- 
drawn in  this  way  ;  cheesy  particles  will  not  pass  through  the  canula,  and 
in  order  to  overcome  this  difficulty,  it  is  the  practice  to  inject  some  '  modi- 
fying fluid  '  with  the  object  of  rendering  the  contents  thinner  and  able  to 
flow  through  the  canula  at  the  next  aspiration.  For  this  purpose  it  is 
usual  to  inject  from  15-60  minims  of  a  saturated  solution  of  iodoform  in 
ether,  according  to  the  size  of  the  abscess,  after  as  much  of  the  fluid  con- 
tents of  the  abscess  as  possible  has  been  withdrawn.  When  this  fluid  is 
injected,  the  heat  of  the  body  volatilises  the  ether,  which  escapes  through 
the  canula,  leaving  the  iodoform  diffused  over  the  abscess.  When  all  the 
ether  has  escaped,  the  needle  is  withdrawn.  For  full  particulars  of  this 
method  the  reader  should  consult  an  interesting  paper  by  Calve  and 
Gauvain  (Lancet,  March  5,  1910).  The  chief  objection  to  the  operation  is 
that  it  needs  to  be  repeated  on  several  occasions ;  its  chief  advantage  is 
that  it  does  not  need  a  general  anaesthetic. 

It  is  needless  to  say  that  these  operations  must  be  performed  strictly 
antiseptically ;  the  entrance  of  septic  organisms  or  even  of  saprophytes 
would  seriously  endanger  the  patient's  life.  Before  the  introduction  of 
antiseptic  treatment  few  cases  of  psoas  abscess  recovered. 

The  general  health  must  be  attended  to  and  good  hygienic  con- 
ditions, absolute  rest  to  the  part,  and  the  administration  of  cod  liver 
oil  and  nourishing  diet,  must  be  insisted  upon.  The  administration  of 
tuberculin  (see  Appendix)  is  also  advisable  in  many  cases.  The  subject 
of  chronic  abscess  has  to  be  considered  again  in  connection  with  tuber- 
culous disease  in  the  various  organs,  but  what  has  been  said  will  suffice 
to  indicate  the  general  principles  of  the  treatment. 


DIVISION    IV. 
TUMOURS. 

CHAPTER   XIII. 

TUMOURS. 

DEFINITION. — Tumours  may  be  defined  as  localised  swellings 
which,  though  part  of  the  body,  grow  continuously  and  independently 
of  it  and  without  relation  to  any  known  cause.  A  tumour  continues 
to  grow,  and,  as  a  rule,  nothing  short  of  its  complete  removal  will 
permanently  arrest  its  development.  It  must  be  distinguished  from 
hyperplasia  on  the  one  hand  and  from  an  inflammatory  swelling  on  the 
other.  Hyperplasia  is  a  simple  increase  in  the  size  of  an  organ,  which, 
however,  retains  its  natural  form  and  structure  and,  as  far  as  we  know, 
its  function ;  inflammatory  swellings  do  not  possess  any  inherent  power 
of  growth  and  only  continue  to  increase  as  long  as  the  causes  which 
give  rise  to  them  continue  to  act. 

Tumours  may  grow  inside  an  investing  capsule  or  they  may  be  devoid 
of  one,  and  they  then  grow  by  invading  the  surrounding  tissues, 
destroying  them  and  taking  their  place  ;  in  some  cases  minute  portions 
of  the  tumour  may  be  carried  by  the  lymphatics  or  blood-vessels  to 
-distant  parts  and  there  give  rise  to  secondary  growths. 

It  is  unnecessary  to  go  fully  into  the  question  of  tumours  here,  because 
their  treatment  must  be  discussed  in  detail  in  connection  with  the  various 
•organs  and  tissues  in  which  they  occur.  We  shall,  however,  make  a  few 
general  remarks  concerning  them  in  order  to  save  repetition  in  the  future. 

CLINICAL  CLASSIFICATION.— Tumours  may  be  classified 
both  from  a  clinical  and  a  histological  point  of  view.  Clinically  they 
are  divided  into  simple  and  malignant  tumours. 

237 


238  TUMOURS 

Simple  Tumours. — By  a  simple  tumour,  such  as  an  ordinary  lipoma, 
is  meant  one  which  is  of  slow  growth  ;  which  does  not  produce  any  con- 
stitutional disturbance,  such  as  wasting  or  cachexia,  unless  it  be  situated 
in  some  vital  organ ;  which  does  not  cause  pain,  unless  its  size  or  its 
situation  causes  it  to  press  upon  nerves ;  which  has  no  inherent 
tendency  to  ulcerate  and  fungate  by  destroying  the  skin  over  it,  and 
only  does  so  when  the  skin  gives  way  as  a  result  of  the  pressure  to 
which  the  bulk  of  the  tumour  subjects  it ;  and  which  does  not  cause 
secondary  growths  elsewhere.  A  simple  tumour  is  generally  surrounded 
by  a  capsule  and  does  not  infiltrate  the  tissues  around,  nor  does  it  recur 
after  being  removed  completely.  It  is  freely  movable  and  readily 
separable  from  the  surrounding  parts,  unless  accidental  attacks  of 
inflammation  have  occurred  about  it ;  in  structure  it  resembles  more 
or  less  closely  some  of  the  normal  tissues  of  the  body. 

Malignant  Tumours. — A  malignant  tumour,  such  as  an  epithe- 
lioma,  usually  grows  rapidly  and  after  a  time  produces  severe  constitu- 
tional effects,  known  as  cachexia,  the  patient  wasting,  becoming  pale  and 
sallow,  and  evidently  suffering  from  chronic  poisoning.  The  growth  is 
often  painful,  apart  from  its  situation,  because  it  involves  nerves,  and 
undergoes  softening ;  when  it  is  near  the  skin  it  may  destroy  it,  and 
lead  to  ulceration  and  fungation.  It  is  not  encapsuled,  any  apparent 
capsule  being  really  a  false  one  and  not  marking  the  true  limits  of 
the  disease.  As  a  rule  it  grows  by  infiltrating  and  destroying  the  sur- 
rounding parts  and  replacing  them  by  tumour  substance,  and  also 
by  producing  secondary  tumours  elsewhere.  Malignant  tumours  are 
usually  hard  and  not  freely  movable,  on  account  of  their  infiltrating 
nature.  They  frequently  recur  after  removal.  In  structure  they 
differ  widely  from  normal  tissues. 

HISTOLOGICAL,  CLASSIFICATION.  --  Histologically 
tumours  are  divided  into  those  composed  of  cellular  elements  and 
those  in  which  the  structure  is  more  complex ;  the  former  are  again 
subdivided,  according  to  the  type  of  cell  that  forms  their  chief  con- 
stituent, into  tumours  composed  of  epithelial  tissues,  and  into  tumours 
of  the  connective-tissue  type.  The  tumours  belonging  to  this  latter 
class  are  not  composed  of  cells  alone,  but  contain  in  addition  blood- 
vessels, connective  tissue,  and  lymphatic  vessels.  So  far  as  we  know, 
however,  they  are  not  provided  with  nervous  elements. 

TUMOURS  OF  THE  CELLULAR  TYPE. 

EPITHELIAL  TUMOURS. 

Epithelial  tumours  are  due  to  the  growth  of  epithelium,  which 
may  be  regular  or  irregular,  and,  if  on  a  free  surface,  may  remain 
heaped  up  in  masses,  or  may  penetrate  into  and  infiltrate  the  tissues 


TUMOURS  OF  THE  CELLULAR  TYPE  239 

beneath.  The  irregular  infiltrating  form  of  epithelial  growth  leads  to 
the  formation  of  the  group  of  malignant  tumours,  known  as  car- 
cinomata ;  the  regular  non-infiltrating  form  gives  rise  to  the  benign 
growths. 

BENIGN  VARIETIES.— Of  this  class  we  have  two  forms— 
namely,  those  in  which  the  epithelium  grows  on  a  free  surface, — the 
papillomata, — and  those  in  which  the  growth  is  in  the  substance  of  the 
tissues, — the  adenomata.  The  papillomata  do  not  strictly  belong  to 
the  tumour  group,  because  many  of  them  are  of  irritative  origin  and 
sometimes  disappear  spontaneously;  nevertheless  it  is  most  convenient 
to  refer  to  them  here. 

Papillomata. — This  group  includes  warts,  or  papillomata  proper, 
corns  and  horns.  Warts  on  the  skin  are  usually  hard  and  sessile,  while 
on  the  mucous  membrane  they  are  soft  and  pedunculated.  The  papillae 
of  which  they  are  composed  may  be  single  or  branched ;  it  is  the 
branched  form  that  gives  rise  to  the  pedunculated  growths  of  which 
the  typical  examples  are  seen  on  the  prepuce. 

Treatment. — A  simple  and  effectual  method  of  treating  ordinary 
hard  warts  on  the  skin  is  to  pare  away  the  dense  epithelium  on  the 
surface  until  the  vascular  tops  of  the  papillae  are  exposed,  and  then  to 
apply  some  caustic  so  as  to  destroy  their  bases  ;  the  one  which  answers 
best  and  leaves  the  least  scar  is  salicjdic  acid.  A  useful  application  is  a 
mixture  of  100  grains  of  salicylic  acid  in  an  ounce  of  flexile  collodion, 
which  is  painted  over  the  wart  after  it  has  been  shaved  down  so  as  to 
expose  the  papillae.  Twelve  hours  later,  as  much  of  the  collodion  as 
will  come  off  readily  is  picked  away  and  a  fresh  layer  applied.  This  is 
repeated  night  and  morning,  and  the  wart  will  generally  be  found  to 
have  withered  away  in  the  course  of  a  week  or  ten  days  ;  should  the 
action  not  be  sufficiently  rapid,  the  wart  should  be  shaved  afresh  from 
time  to  time. 

This  method  may  be  sometimes  employed  for  gonorrhceal  warts 
covering  the  prepuce,  when  a  large  raw  area  would  be  left  if  they  were 
clipped  off  with  scissors.  In  this  case  it  is  not  necessary  to  shave  the 
wart  before  applying  the  caustic.  The  prepuce  should  be  retracted, 
and  the  wart  carefully  dried  and  then  painted  with  the  salicylic  collodion  ; 
this  must  be  allowed  to  dry  before  the  prepuce  is  pulled  forwards,  as 
otherwise  a  sore  may  be  produced  on  the  glans  by  contact  with  the  acid. 
It  is  well  to  introduce  a  piece  of  dry  boric  lint  between  the  glans  and  the 
prepuce  ;  this  absorbs  moisture  and  prevents  contact  between  the 
salicylic  acid  and  the  mucous  membrane  of  the  glans. 

A  more  rapid  method  of  removing  warts  is  the  following.  Apply 
undiluted  carbolic  acid  to  the  wart  after  the  skin  around  has  been 
carefully  greased  in  order  to  prevent  the  acid  from  running  over  the 
normal  skin.  The  carbolic  acid  is  allowed  to  soak  well  into  the  substance 
of  the  wart  between  the  constituent  papilla.  Then  place  a  small  drop  of 


240  TUMOURS 

pure  nitric  acid  in  the  centre  of  the  wart  ;  this  produces  a  brisk 
effervescence  accompanied  by  destruction  of  the  whole  warty  tissue. 
Although  the  chemical  action  seems  to  be  extremely  violent  the  method 
is  not  particularly  painful,  the  carbolic  acid  acting  to  a  certain  extent 
as  a  local  anaesthetic.  The  CO2  freezing  method  (see  p.  262)  recom- 
mended for  naevi  is  also  of  great  value.  In  treating  crops  of  warts 
it  very  often  happens  that  when  one  or  two  of  the  largest  are  cured 
the  rest  disappear  spontaneously. 

Should  these  methods  prove  ineffectual,  the  wart  must  be  removed 
by  the  knife.  When  papillomata  are  sessile  and  are  situated  on  the  skin, 
it  is  not  sufficient  to  clip  them  off,  as  they  will  certainly  grow  again  ;  it 
is  necessary  to  excise  their  bases. 

When  the  papillomata  are  pedunculated,  and  the  pedicle  is  narrow, 
it  is  best  to  clip  them  off  with  scissors,  and  to  paint  the  cut  surface  for 
a  few  days  in  succession  with  salicylic  collodion  (see  p.  239).  The 
papillomata  of  the  bladder  or  rectum  must  be  removed  by  special 
operations,  which  are  described  in  their  appropriate  places. 

Horns. — In  these  cases  the  epithelium  remains  heaped  up  in  masses 
over  the  surface  of  the  papillae,  and  becomes  hard  and  stuck  together  by 
some  glutinous  material.  On  breaking  off  the  horn,  a  broad  papillo- 
matous  base  is  left  which  must  be  dissected  away ;  unless  this  be  done, 
the  horn  will  grow  afresh. 

Corns. — A  corn  is  due  essentially  to  intermittent  pressure,  and  as  a 
rule  removal  of  the  pressure  will  lead  first  to  the  peeling  off  of  the  hard 
core  of  the  corn,  and  subsequently  to  its  complete  disappearance.  Salicylic 
collodion  (vide  supra]  applied  after  paring  the  corn,  will  facilitate 
its  disappearance  ;  a  corn,  however,  needs  more  frequent  paring  than 
a  wart.  A  more  certain  effect  may  be  obtained  by  shaving  down  the 
epithelium,  and  applying  a  thick  bunion  plaster  so  that  its  centre  is  over 
the  base  of  the  corn.  The  hole  in  the  centre  of  the  plaster  is  then  filled 
up  with  pure  salicylic  acid  and  a  piece  of  ordinary  plaster  is  put  on  over 
the  bunion  plaster  to  keep  the  salicylic  acid  in  place.  The  acid  thus  acts 
directly  upon  the  base  of  the  corn  and  is  very  effectual.  The  applica- 
tion should  be  renewed  daily  as  long  as  may  be  necessary,  any  epi- 
dermis that  can  be  picked  away  easily  being  removed  before  each  fresh 
application. 

Adenomata. — These  tumours  occur  in  connection  with  glands, 
and  in  structure  are  similar  to  that  of  the  gland  in  which  they  develop. 
It  is  uncertain  whether  they  originate  in  a  hyperplasia  of  the  epithelium 
or  of  the  connective  tissue,  but  as  a  rule  so  much  fibrous  tissue  is  present 
that  the  term  fibro-adenoma  is  more  appropriate  ;  if  the  tissue  be  very 
embryonic  the  term  myxo-adenoma  is  used.  The  adenomata  are 
usually  encapsuled,  and,  when  embedded  in  the  substance  of  the  organ, 
can  generally  be  shelled  out  of  their  capsule  without  any  tendency  to 
recurrence. 


TUMOURS   OF  THE  CELLULAR  TYPE  241 

Treatment. — The  treatment  is  to  shell  them  out  of  their  capsule. 
In  certain  positions — e.g.  in  the  rectum  or  oesophagus — adenomata 
become  polypoid,  and  are  dragged  down  wards  by  their  weight,  pushing 
the  mucous  membrane  before  them.  In  these  cases  the  polypoid  growth 
is  cut  off  after  ligature  of  the  pedicle  to  arrest  the  bleeding. 

MALIGNANT  FORMS.— The  second  great  group  of  epithelial 
growths  is  formed  by  the  carcinomata,  in  which  the  epithelium  grows  in 
an  irregular  manner  ;  the  cells  are  larger  than  the  ordinary  epithelial 
ones  from  which  they  originate,  and  the  growths  infiltrate  the  tissues 
and  are  not  encapsuled. 

Carcinomata. — The  carcinomata  differ  in  malignancy  and  rapidity 
of  growth  according  to  their  situation,  to  the  character  of  the  epithelium 
in  connection  with  which  they  grow,  and  to  other  circumstances  with 
which  we  are  not  well  acquainted.  The  carcinomata  which  spring  from 
the  surface  epithelium  are  generally  spoken  of  as  epitheliomata,  and  this 
class  includes  squamous  epithelioma,  and  rodent  ulcer,  growing  from  the 
skin,  and  the  cylindrical  epitheliomata,  springing  from  the  intestinal 
canal,  etc.  Those  which  originate  from  glandular  epithelium  are  termed 
the  carcinomata  proper. 

The  eapeinomata  proper  also  form  several  groups.  There  is  a  very 
soft  kind  formerly  called  encephaloid  cancer,  in  which  the  cells  are 
numerous  and  the  fibrous  tissue  small  in  amount.  They  usually  grow 
rapidly  and  may  be  very  malignant.  In  marked  contrast  to  these  is  the 
atrophic  scirrhus,  in  which  the  cells  atrophy  quickly,  and  the  growth 
contains  a  large  amount  of  fibrous  tissue  with  only  few  alveoli  and  cellular 
elements.  These  tumours  grow  extremely  slowly  and  never  attain 
any  great  size.  Intermediate  between  these  two  extremes  are  all 
gradations. 

Mode  of  Spread. — The  essential  growing  element  in  the  carcino- 
mata is  the  epithelial  cell,  and  the  character  of  the  growth  depends 
upon  the  mode  in  which  these  cells  spread.  The  epithelial  cells  are 
usually  found  enclosed  in  tubular  spaces  termed  alveoli,  which  are  prob- 
ably dilated  and  much  altered  lymph  spaces;  at  any -rate  they  com- 
municate freely  with  the  lymphatics.  The  cells  are  evidently  derived 
from  the  normal  epithelium  of  the  part  in  which  the  disease  primarily 
begins,  but  they  soon  multiply  independently  and  show  active  processes 
of  growth.  They  rapidly  push  their  way  through  the  limiting  membrane 
of  the  normal  epithelium  into  the  tissues  around,  and  there  spread  in 
the  lymph  spaces  and  channels  ;  at  the  same  tune  it  would  appear  that 
they  attack  the  walls  of  the  smaller  veins,  and  spread  into  their  interior 
at  an  early  period,  although  metastatic  deposits,  due  to  infection  through 
the  blood-vessels,  seldom  show  themselves  clinically  until  late  in  the 
course  of  the  disease. 

After  spreading  into  the  lymphatic  vessels,  the  cells  become  detached 
and  carried  with  the  lymph  stream,  and  either  become  arrested  in 


242  TUMOURS 

the  vessels  when  these  are  small  and  the  cells  are  large  or  massed 
together  in  groups  ;  or  they  are  carried  on  to  and  caught  by  the  nearest 
lymphatic  glands,  where  they  give  rise  to  secondary  tumours.  From 
the  nearest  lymphatic  glands  they  spread  to  others  in  the  neighbourhood, 
and  thus  fresh  groups  of  glands  are  affected.  Ultimately  they  get  into 
the  blood-vessels,  either  indirectly  through  the  thoracic  duct,  or  directly 
by  penetrating  the  walls  of  the  veins.  They  are  thus  finally  deposited 
in  various  organs  in  distant  parts  of  the  body.  Hence,  in  carcinomatous 
tumours,  we  have  a  primary  tumour,  a  secondary  glandular  infection, 
and  internal  or  metastatic  deposits. 

Furthermore,  certain  special  degenerations  occur  in  some  forms, 
such  as  colloid  degeneration  in  carcinoma  of  the  stomach  and  intestine, 
and  a  form  of  degeneration  accompanied  by  the  deposit  of  pigment  which 
is  generally  spoken  of  as  melanotic  cancer. 

Treatment. — If  carcinomatous  disease  is  to  be  rooted  out,  its  mode 
of  spread  by  means  of  the  lymphatic  vessels  must  be  borne  in  mind,  and 
as  this  occurs  at  an  early  stage,  and  as  the  cells  are  microscopic,  a  very 
wide  area  must  be  removed  by  the  knife.  The  organ  from  which  the 
original  growth  springs  should,  if  practicable,  be  excised,  because  its 
lymphatic  vessels  generally  communicate  freely  with  each  other  and 
there  are  probably  secondary  deposits  in  various  parts  of  it  already.  In 
addition,  the  nearest  chain  of  lymphatic  glands  must  also  be  removed, 
even  though  the  glands  may  not  be  noticeably  enlarged. 

It  is  sometimes  difficult  to  decide  whether  the  lymphatic  tract  inter- 
vening between  the  primary  growth  and  the  glands  should  also  be  removed. 
That  this  should  be  done  in  certain  cases — as  for  example,  in  breast  cancer — 
is  evident  from  microscopical  researches,  which  have  shown  that  the 
lymphatic  vessels  passing  from  the  breast  to  the  axillary  glands  are 
themselves  affected  in  the  great  majority  of  advanced  cases.  On  the 
other  hand,  there  are  certain  forms  of  carcinoma,  especially  of  the  squamous 
epithelial  type,  in  which  the  intervening  lymphatics  do  not  seem  to  be 
readily  infected.  In  epithelioma  of  the  lip,  for  instance,  a  secondary 
tumour  rarely  arises  in  the  course  of  the  lymphatic  vessels,  although  the 
glands  of  the  neck  may  be  enlarged.  In  epithelioma  of  the  extremities 
also,  the  lymphatic  vessels  are  not  usually  affected,  although  the  glands 
become  involved  comparatively  early.  Hence,  in  these  cases,  it  suffices 
in  the  first  instance  to  remove  the  primary  growth  and  the  nearest 
lymphatic  glands,  and  then  to  watch  whether  recurrence  takes  place  in 
the  intervening  tissues.  In  breast  cancer,  on  the  other  hand,  it  is  wiser 
to  take  away  not  only  the  breast  and  the  axillary  glands,  but  all  the 
intervening  fat  and  fascia  with  the  lymphatic  vessels  running  in  them, 
if  we  wish  to  make  sure  of  avoiding  recurrence  ;  this  also  applies  to 
cancer  in  most  other  situations.  Details  of  the  various  operations  are 
given  in  connection  with  the  affections  of  the  individual  parts  and 
organs. 


TUMOURS   OF  THE  CELLULAR  TYPE  243 

Radium  is  useful,  when  sufficient  is  available,  in  some  superficial 
forms  of  epithelioma  that  cannot  be  removed  sufficiently  widely.  It  is 
chiefly  used  at  the  present  time  in  connection  with  rodent  ulcer  (see 
p.  249),  for  which  it  is  very  effectual.  For  true  epithelioma  it  should 
not  be  used  as  a  substitute  for  excision. 

Endotheliomata. — This  term  includes  a  large  group  of  tumours 
which  are  very  diverse  clinically,  some  being  highly  malignant,  while 
others  are  to  all  intents  and  purposes  innocent.  They  grow  from  the 
endothelial  lining  of  blood-vessels,  from  the  lining  of  the  perivascular 
lymphatic  spaces,  from  the  endothelium  of  the  tissue  lymph-spaces  and 
lymph-vessels,  and  from  the  surface  of  the  serous  membranes.  Clinically 
they  do  not  present  any  special  characteristics  and  in  practice  can  be 
treated  in  accordance  with  the  clinical  signs  ;  that  is  to  say,  those  tumours 
which  exhibit  the  characteristics  of  malignant  disease  should  be  treated 
as  malignant,  while  those  which  resemble  simple  innocent  tumours  should 
be  treated  as  innocent. 


TUMOURS  OF  THE  CONNECTIVE-TISSUE  TYPE. 

These  are  of  two  kinds — viz.  those  in  which  the  connective  tissue  is 
embryonic  in  character — e.g.  sarcomata  and  myxomata;  and  those  in 
which  the  connective  tissue  is  more  fully  formed — e.g.  fibromata  and 
lipomata. 

MALIGNANT  FORMS.— The  Sarcomata  form  fleshy  tumours 
composed  of  embryonic  connective  tissue.  They  are  rounded  and  nodular 
and  generally  have  a  spurious  capsule,  which  is  composed  of  sarcomatous 
tissue  and  must  be  looked  upon  as  an  integral  part  of  the  growth  itself. 
They  vary  in  malignancy,  but  all  possess  to  some  extent  a  decidedly  malig- 
nant character.  They  may  occur  wherever  there  is  connective  tissue,  and 
are  most  frequently  met  with  in  the  bones,  fasciae,  muscles,  skin,  breast, 
testicle,  uterus,  kidney,  parotid,  and  nerves.  The  cells  vary  in  character, 
and  the  sarcomata  are  therefore  subdivided  into  a  number  of  varieties 
according  to  the  general  character  of  the  cells  composing  them.  In 
addition  to  the  cells  there  is  a  certain  amount  of  intercellular  substance 
which  varies  in  degree  and  stage  of  organisation  with  the  class  to  which 
the  tumour  belongs.  The  consistence  and  appearance  of  the  tumour 
depends  to  a  great  extent  on  the  amount  of  intercellular  substance  present. 

These  growths  are  usually  very  vascular  and  are  especially  rich  in 
capillaries  and  veins.  They  may  undergo  various  degenerations  ;  they 
compress  and  destroy  neighbouring  parts,  surround  vessels  and  nerves, 
and  may  lead  to  ulceration  of  the  skin,  either  after  involving  it  or,  more 
commonly,  by  causing  sloughing  from  pressure  and  then  fungating  through 
the  opening  thus  formed.  They  give  rise  to  secondary  tumours  around 
the  primary  one,  or  spread  through  the*  medium  of  the  circulation.  The 
secondary  internal  tumours  occur  most  commonly  in  the  lungs  and  the 


R  2 


244 


TUMOURS 


liver.  In  the  softer  and  more  embryonic  varieties,  the  lymphatic  glands 
may  become  affected ;  though  this  is  not  nearly  so  common  as  in  the 
carcinomata. 

Of  the  varieties  of  the  sarcomata  may  be  mentioned  the  round-celled 
sarcoma,  which  is  usually  soft  and  white  like  the  milt  of  fish,  and  very 
malignant ;  the  spindle-celled  sarcoma,  which  is  generally  firmer,  of  a 
greyish  or  yellowish-white  appearance,  and  not  so  malignant  as  the  round- 
celled  variety  ;  it  occurs  most  frequently  in  connection  with  the  fasciae  ; 
the  myeloid  sarcoma,  in  which  there  are  myeloid  or  giant  cells  in  addition 
to  polymorphous  or  spindle  cells.  This  form  is  soft,  of  a  chocolate  colour, 
and  generally  contains  numerous  cysts,  due  to  degeneration  occurring 
in  connection  with  the  myeloid  cells.  It  occurs  in  the  interior  of  the 
articular  ends  of  bones,  and  in  the  lower  jaw.  It  is  the  least  malignant 
of  the  sarcomata  and  seldom  gives  rise  to  secondary  tumours ;  it 
may  often  be  removed  without  amputation  and  without  recurrence. 
Some  authors  separate  these  myeloid  tumours  from  the  sarcomata  and 
place  them  in  a  group  by  themselves  under  the  name  of  myelomata. 

The  melanotie  sarcomata  contain  polymorphous  or  spindle-shaped 
cells  in  which  early  pigmentary  degeneration  occurs.  They  originate  in 
parts  where  there  is  normally  pigment,  such  as  the  skin  or  the  choroid. 
They  are  the  most  malignant  of  the  sarcomata,  affecting  the  glands  early, 
and  recurring  with  great  rapidity.  Alveolar  sarcoma  is  comparatively 
rare.  In  it  the  cells  are  arranged  in  groups  separated  by  connective 
tissue  or  spindle  cells,  giving  rise  to  an  alveolar  arrangement.  Osteo- 
sareoma  takes  origin  from  the  periosteum  and  is  extremely  malignant ; 
a  certain  amount  of  ossification  takes  place  in  it,  so  that  spicules 
of  osseous  tissue  are  found  projecting  from  its  surface  when  the 
affected  bone  is  macerated.  The  secondary  deposits  to  which  this  form 
gives  rise  are  apt  to  undergo  similar  ossification.  A  somewhat  analogous 
condition  is  seen  in  the  variety  known  as  chondro-sareoma,  which  is 
met  with  sometimes  in  soft  tissues,  such  as  the  testicle  or  the  parotid, 
and  in  which  chondrification  occurs  ;  it  is  a  very  malignant  form. 

Treatment. — All  sarcomata  should  be  excised  freely.  Any  capsule 
that  the  tumour  possesses  must  be  taken  away ;  in  fact,  it  is  well  to  make 
sure  that  a  considerable  area  of  healthy  tissue  beyond  the  capsule  is 
included  in  the  removal.  When  the  sarcoma  arises  in  connection  with 
bone,  amputation  is  generally  necessary,  and  moreover,  in  cases  of 
periosteal  sarcoma  it  is  advisable  to  disarticulate  through  the  joint  above 
the  bone  affected,  because  it  will  be  found  on  microscopical  examination 
that  the  growth  generally  spreads  in  the  periosteum  to  a  considerable 
distance  beyond  the  naked-eye  limits  of  the  tumour,  and  recurrence  is 
likely  to  take  place  if  amputation  be  performed  in  the  continuity  of  the 
bone. 

Myeloid  tumours,  however,  form  an  exception  to  the  rule  that  sarcomata 
of  bone  call  for  amputation ;  such  a  procedure  is  rarely  called  for  in  them. 


TUMOURS  OF  THE  CELLULAR  TYPE  245 

If  the  growth  be  large  and  occupy  the  whole  thickness  of  the  bone,  a 
free  excision  of  the  affected  area  will  suffice  ;  when  the  growth  is  in  the 
articular  end,  a  partial  excision  of  the  joint  will  be  called  for.  When, 
however,  the  growth  is  small  and  only  occupies  a  small  part  of  the  thick- 
ness of  the  bone,  so  that  sufficient  bone  will  be  left  to  bear  the  weight 
of  the  body,  it  is  not  even  necessary  to  excise  ;  the  growth  may  be  scraped 
out  without  much  fear  of  a  recurrence,  though  it  is  well  to  take  away  a 
thin  slice  of  the  wall  of  the  cavity  if  possible. 

The  prognosis  in  all  these  tumours,  if  left  to  themselves,  is  very 
grave.  With  the  exception  of  the  myeloid  sarcomata  they  are  always 
dangerous  to  life.  The  result  of  operation  is  more  favourable  on  the 
whole  than  in  carcinoma,  except  in  the  case  of  melanotic  sarcoma  and  the 
osteo-sarcomata,  which  are  extremely  malignant  forms.  In  the  case  of 
the  other  forms  recurrence,  though  not  infrequent,  is  often  only  local,  and 
the  secondary  tumours  may  be  removed  again  and  again  as  they  appear. 
In  all  cases  a  wide  sweep  must  be  made,  and  a  considerable  amount  of  the 
tissues  around  must  be  taken  away ;  there  must  be  no  attempt  to  shell 
the  growth  out  of  its  capsule.  The  treatment  for  the  mixed  forms,  such 
as  myxo-sarcoma  and  nbro-sarcoma,  is  the  same  as  for  the  others. 

GENERAL  POINTS   CONCERNING  THE  TREATMENT  OF 
MALIGNANT  TUMOURS. 

What  has  been  said  above  will  serve  to  indicate  the  main  lines  of 
treatment  to  be  adopted  for  malignant  tumours  in  general.  The 
details  of  individual  operations  for  the  removal  of  malignant  tumours 
are  fully  discussed  in  connection  with  the  various  organs  and  parts 
of  the  body  in  which  they  occur.  But  there  are  a  number  of  points 
applicable  to  operations  for  malignant  disease  in  general  to  which  it 
is  well  to  refer  here. 

EXPLORATORY  INCISION  FOR  DIAGNOSIS.— It  is 
not  always  easy  to  be  certain  of  the  diagnosis,  especially  when  the 
tumour  is  deep-seated,  and  the  appropriate  operative  procedure  cannot 
be  undertaken  until  the  nature  of  the  tumour  is  known.  When  the 
tumour  is  superficial  it  is  easy  to  remove  a  suitable  portion  of  the  growth 
and  subject  it  to  microscopical  examination.  When,  however,  the  growth 
is  more  deeply  seated,  it  may  be  necessary  to  cut  down  upon  the  tumour 
in  order  to  ascertain  its  real  nature. 

In  making  an  exploratory  incision  in  a  case  of  suspected  malignant 
disease,  the  possibility  of  infecting  the  wound  from  the  growth  and  of 
disseminating  the  disease  must  never  be  lost  sight  of.  To  cut  through 
presumably  healthy  tissues,  and  then  to  cut  into  and  remove  a  portion 
of  a  malignant  tumour,  means  that  the  cells  of  the  malignant  growth 
will  certainly  be  scattered  over  the  surface  of  the  wound  and  may 
infect  it  if  the  wound  be  sewn  up,  as  was  frequently  done  at  one  time. 


246  TUMOURS 

If  a  portion  of  the  tumour  be  removed  for  examination  at  one  operation, 
the  wound  then  closed,  and  another  radical  operation  be  undertaken  at  a 
later  date  when  the  nature  of  the  disease  has  been  revealed  by  the  micro- 
scope, the  probability  will  be  that  many  new  points  of  growth  will  have 
already  developed  and  that  the  infection  will  have  become  disseminated 
over  a  wide  area.  Hence,  in  making  an  exploratory  operation  it  is  most 
important  to  avoid  infecting  the  healthy  portions  of  the  \vound  with 
material  from  the  tumour,  and  not  to  allow  any  long  time  to  elapse 
between  the  exploration  and  the  radical  operation,  if  one  be  decided  on. 
It  is  only  when  a  radical  operation  is  possible,  should  the  tumour 
turn  out  to  be  malignant,  that  an  exploratory  incision  into  the  mass 
is  allowable. 

If  it  can  be  avoided,  no  tumour  suspected  of  malignancy  should  be 
incised  in  situ  ;  the  whole  tumour  should  be  removed  before  incising  it. 
A  doubtful  tumour  of  the  breast,  for  example,  should  be  cut  out  entire  and 
examined  outside  the  body.  Even  then  it  is  impossible  to  be  sure  that 
lymphatic  vessels  containing  tumour  cells  may  not  be  cut  through ;  but 
the  risk  of  infecting  the  wound  is  very  much  less  than  if  an  incision 
were  made  directly  into  the  tumour  itself.  When  it  is  not  feasible  or 
advisable  to  remove  the  tumour  in  the  first  instance  and  examine  it 
outside  the  body,  there  may  be  enlarged  glands  in  the  neighbourhood 
which  can  be  taken  away  and  subjected  to  microscopical  examination. 
All  instruments  or  gloves  employed  in  this  preliminary  operation  should 
be  looked  upon  as  probably  infected,  and  if  a  further  operation  be  pro- 
ceeded with  at  the  time,  fresh  instruments  and  gloves  should  be  used. 
The  exploration  should  be  followed  by  the  radical  operation,  if  it 
be  decided  to  carry  that  out,  with  the  least  possible  loss  of  time. 
Hence,  leave  should  be  obtained  to  proceed  \vith  this  forthwith  after 
the  exploration  has  been  made.  It  is  well  to  have  a  pathologist 
present  at  the  exploration,  who  will  make  a  rapid  section  and  give  a 
microscopical  diagnosis  of  the  tumour  on  the  spot.  As  a  rule,  this  only 
means  a  short  delay,  during  which  the  patient  can  be  kept  lightly  under 
the  anaesthetic. 

OPERATIONS. — After  the  true  nature  of  the  tumour  has  been 
determined,  the  question  of  the  most  suitable  operation  arises.  The 
operations  done  for  malignant  disease  may  be  divided  into  three  large 
groups — namely :  (i)  Radical  operations,  performed  with  the  view  of 
ridding  the  patient  of  the  disease  altogether ;  (2)  Partial  operations,  with 
the  view  of  relieving  the  patient  of  a  source  of  local  pain  or  distress  ;  and 
(3)  Palliative  operations,  in  which  the  tumour  itself  is  not  interfered  with, 
but  some  of  the  troubles  to  which  it  is  giving  rise  are  relieved. 

Radical  Operations. — The  essence  of  a  radical  operation  is  to  remove 
along  with  the  tumour  a  considerable  area  of  the  surrounding  tissues, 
so  as  to  take  away  as  widely  as  possible  the  areas  along  which  the 
disease  naturally  spreads. 


TUMOURS  OF  THE  CELLULAR  TYPE  247 

The  difference  between  radical  operations  for  carcinoma  and  sarcoma 
respectively  depends  on  the  mode  of  spread  of  the  disease  in  the  two 
cases.  In  both  the  incisions  should  pass  through  healthy  tissues  at 
some  distance  from  the  disease  ;  in  both  any  organ  in  which  the  tumour 
started  should  be  completely  removed ;  and  in  both,  if  glands  be  infected, 
a  similarly  free  removal  of  lymphatics  and  glands  is  indicated.  A 
difference  arises,  however,  in  the  two  forms  as  regards  the  latter  point. 
In  the  case  of  sarcomata  the  glands  need  only  be  removed  when  they  are 
evidently  affected  ;  in  carcinomata  the  neighbouring  lymphatic  area 
must  be  cleared  out  in  any  case  A  radical  operation  should  be 
recommended  when  it  is  possible  to  remove  all  the  visible  disease  with 
a  reasonable  chance  of  non-recurrence  and  of  prolongation  of  life,  and 
without  such  mutilation  as  to  make  life  unendurable.  It  is  unnecessary 
to  remark  that  the  patient  should  never  be  advised  to  submit  to  what 
purports  to  be  a  radical  operation  unless  the  surgeon  has  every  reason  to 
believe  that  he  can  remove  all  the  visible  disease ;  but  it  frequently  happens 
that,  while  this  is  possible,  the  operation  may  probably  be  followed 
by  early  recurrence,  or  certainly  by  most  serious  mutilation.  A  good 
example  of  such  a  case  as  this  is  an  operation  for  cancer  involving  the 
larynx  and  pharynx.  Apart  from  the  great  probability  of  early  recur- 
rence, the  miserable  condition  in  which  the  patient  will  be  left  must  be 
taken  fully  into  account.  If  he  be  well-to-do,  and  able  to  have  the  necessary 
attendance,  and  if  his  pursuits  be  intellectual,  he  may  be  fairly  content 
to  live  under  such  conditions  ;  but  a  man  without  financial  or  intellectual 
resources  will  suffer  so  greatly  that  a  temporary  prolongation  of  life 
under  such  circumstances  offers  no  real  recompense  for  the  sufferings 
entailed  by  the  operation.  The  patient  ought  always  to  be  fully  informed 
of  the  extent  of  the  operation,  the  chances  of  recurrence,  and  the  final 
functional  result,  before  he  comes  to  a  decision,  and  this  decision  should 
be  left  to  him ;  the  surgeon  should  content  himself  with  placing  the 
facts  fully  before  him. 

There  is  no  method  except  operation  by  which  malignant  disease 
other  than  rodent  ulcer  can  be  eradicated.  Rodent'  ulcer  is  a  form  of 
local  malignant  disease  with  a  distinct  life-history,  and  is  in  many  in- 
stances apparently  cured  by  radium.  There  is  no  evidence,  however, 
that  any  of  the  other  forms  of  malignant  disease  can  be  cured  by  this  or 
any  other  substance,  and  it  is  unjustifiable  to  subject  a  case  favourable 
for  operative  treatment  to  any  other  method  in  the  first  instance. 

Partial  Operations.  —  It  is  never  desirable  merely  to  cut  away  a 
portion  of  a  tumour,  but  it  is  sometimes  well  worth  while  to  remove  a 
primary  growth,  even  though  irremovable  secondary  growths  may  be 
present ;  similarly  it  may  sometimes  be  advisable  to  remove  secondary 
growths  that  are  causing  suffering,  even  though  the  primary  growth  cannot 
be  excised.  These  statements,  however,  are  subject  to  the  qualification 
that  it  is  not  advisable  to  remove  a  mass  which  is  likely  to  recur  in  situ 


248  TUMOURS 

almost  at  once.  A  good  example  of  this  may  be  seen  in  cases  of  cancer  of 
the  tongue  of  comparatively  limited  extent,  in  which  there  is  extensive 
involvement  of  glands  that  cannot  be  removed.  In  a  case  like  this  the 
patient's  sufferings  are  mainly  due  to  the  growth  of  the  cancer  in 
the  tongue,  and  much  pain  and  distress  may  be  saved  by  removing  the 
disease  in  the  tongue  without  attempting  to  remove  the  infected  glands.  It 
is  also  sometimes  possible  and  advisable  to  remove  an  ulcerating  cancer 
of  the  breast  so  freely  as  to  make  immediate  recurrence  at  the  site  of 
operation  improbable,  although  the  co-existing  glandular  infection  may 
be  so  extensive  that  there  is  no  hope  of  ridding  the  patient  of  the  disease. 
It  also  happens  not  infrequently  that  a  cancer  of  the  intestine  causes 
obstruction,  but  can  be  excised  though  there  are  secondary  growths 
present  which  cannot  be  got  rid  of ;  here  an  enterectomy  may  save  the 
patient  much  suffering  and  discomfort.  It  is  important,  however,  to  be 
quite  sure  that  operation  is  for  the  benefit  of  the  patient  before  such 
partial  procedures  are  undertaken. 

Palliative  Operations. — When  the  tumour  is  inoperable,  the  condition 
of  the  patient  may  sometimes,  nevertheless,  be  improved  by  operations 
in  which  the  disease  is  not  interfered  with. 

The  best  example  of  operations  of  this  type  are  the  various  short- 
circuiting  operations  done  in  connection  with  the  intestinal  tract — for 
example,  colostomy  for  rectal  cancer,  gastro-jejunostomy  for  pyloric 
cancer,  or  tracheotomy  for  larnygeal  cancer. 

Sometimes  malignant  disease  gives  rise  to  intense  pain  which  does  not 
yield  to  sedatives,  and  benefit  may  be  derived  by  dividing  the  sensory 
nerves  concerned,  or  even  by  the  division  of  the  posterior  spinal  nerve 
roots.  Another  example  of  an  operation  designed  to  improve  the 
condition  of  the  patient  without  direct  interference  with  the  growth  is 
the  attempt  to  cut  off  the  circulation  to  the  affected  part  and  so  to  starve 
the  growth.  Thus  in  cancer  of  the  tongue,  the  circulation  through  the 
lingual  arteries  may  be  obstructed  by  injecting  boiling  water  into  them  ; 
this  plan  has  occasionally  resulted  in  a  remarkable  improvement. 

THE  TREATMENT  OF  INOPERABLE  CASES.— When 
a  case  is  unsuitable  for  a  radical  operation,  partial  or  palliative  operations 
will  be  adopted  if  they  are  suitable ;  but  in  addition  it  is  often  well,  if  only 
for  the  patient's  peace  of  mind,  to  adopt  any  measures  that  may  arrest 
or  delay  the  progress  of  the  growth,  and  it  is  here  that  radium,  X-rays, 
and  other  palliative  measures  are  useful.  These  measures  sometimes 
appear  to  delay  the  progress  of  the  disease,  and  they  may  relieve  the 
patient's  sufferings  considerably,  while  they  frequently  give  hope  to 
patients  and  their  friends,  and  thus  alleviate  the  anxiety  inseparable 
from  a  case  in  which  further  operative  treatment  has  been  abandoned. 
Many  remedies  for  inoperable  cancer  have  been  introduced,  but  the 
majority  of  them  are  useless  ;  there  are  some,  however,  which  are  worth 
mention. 


TUMOURS  OF  THE  CELLULAR  TYPE  249 

Radium  is  of  great  value  in  rodent  ulcer,  and  claims  are  being  made 
for  it  in  other  forms  of  malignant  disease  ;  as  yet,  however,  there  is  no 
clear  evidence  that  it  has  any  permanent  value  in  these  cases.  It  is  quite 
reasonable,  however,  to  employ  it  for  inoperable  cases,  and  when  large 
supplies  of  radium  can  be  obtained,  and  it  can  be  brought  into  close 
contact  with  the  malignant  disease,  good  results  may  follow.  At  the 
present  time  the  supply  of  radium  is  small  and  is  in  the  hands  of  only  a 
few  persons.  It  is  therefore  unnecessary  to  go  into  details  as  to  its 
method  of  application. 

The  use  of  X-rays  is  on  a  similar  footing.  Good  results  occasionally 
follow  their  use  in  superficial  cancers  ;  for  example,  some  of  the  dis- 
seminated nodules  over  the  chest  in  cancer  of  the  breast  may  dwindle 
and  even  disappear.  But  the  rays  are  apparently  unable  to  penetrate 
and  destroy  cancer  cells  situated  in  deeper  parts.  Nevertheless,  a  course 
of  X-ray  treatment  may  be  of  distinct  value  in  obtaining  healing  of  an 
ulcerating  surface,  and  delaying  the  spread  of  the  disease.  The  pain 
from  which  the  patients  suffer  is  often  relieved  by  the  rays. 

A  vaccine  made  from  the  micrococcus  neoformans  has  been  intro- 
duced, and  in  some  cases  marked  by  severe  cachexia  the  general  con- 
dition of  the  patient  has  improved  noticeably  under  its  use  ;  we  cannot 
say,  however,  that  we  have  observed  any  definite  action  on  the  growth 
itself. 

Coley's  Fluid. — Acting  on  the  observation  that  in  some  cases 
sarcomata  improve  and  even  disappear  entirely  after  an  attack  of 
erysipelas,  Coley  introduced  a  fluid  composed  of  a  mixed  cultivation  of 
streptococcus  erysipelatosis  and  micrococcus  prodigiosus,  in  which  the 
organisms  have  been  killed  by  heat.  The  injection  of  this  fluid  into 
the  tumour  or  into  other  parts  of  the  body  has  been  followed  by  the  dis- 
appearance of  the  growth  in  a  certain  number  of  cases,  while  in  other 
instances  no  effect  has  been  produced.  The  growths  that  have  proved 
most  amenable  to  the  use  of  Coley's  fluid  are  spindle-celled  sarcomata. 

The  injections,  commencing  with  a  dose  of  half  a  minim,  must  be 
made  with  strict  antiseptic  precautions.  This  dose  usually  only  produces 
a  slight  malaise,  but  there  may  be  severe  constitutional  disturbance  in 
susceptible  patients,  the  temperature  rising  to  103°,  with  headache, 
rigors,  and  all  the  symptoms  of  septic  absorption,  while  there  is  swelling, 
redness,  pain,  and  tenderness  at  the  seat  of  the  injection;  if,  however, 
the  injection  has  been  made  with  full  antiseptic  precautions  there  is  no 
risk  of  an  abscess  forming.  When  there  is  no  reaction,  the  dose  may  be 
repeated  next  day,  preferably  into  some  other  part  of  the  body ;  on 
the  third  day  half  a  minim  may  be  injected  into  the  tumour  and  another 
half  into  the  flank.  From  this  point  onwards,  the  dose  may  be  increased 
by  a  minim  a  day  until  a  reaction  occurs  ;  this  usually  takes  place  about 
the  end  of  the  first  week.  The  injections  must  now  be  governed  by  the 
temperature,  the  object  being  to  get  a  well-marked  rise  of  temperature 


250  TUMOURS 

after  each  injection  without  unduly  exhausting  the  patient.  The  maxi- 
mum dose  is  about  fifteen  minims,  and  when  this  has  been  reached,  two 
or  three  injections  a  week  will  suffice.  If  it  be  necessary  to  discontinue 
the  treatment,  in  order  to  enable  the  patient  to  recover  from  its  effects, 
the  dose  given  on  resuming  should  be  slightly  smaller  than  that  last 
injected.  The  treatment  should  be  continued  until  the  tumour  has 
disappeared  entirely  or  until  it  is  certain  that  no  benefit  is  being  derived 
from  it. 

The  operation  of  ob'phorectomy  was  introduced  by  Sir  George 
Beatson  of  Glasgow  for  inoperable  cancer  of  the  breast ;  it  is  founded 
on  the  view  that  there  is  a  definite  functional  connection  between  the 
ovaries  and  the  breast,  and  there  is  no  doubt  that  cancerous  masses 
in  the  breast  have  disappeared  in  several  instances  after  removal  of 
the  ovaries.  Unfortunately,  however,  this  disappearance  seems  to  be 
only  temporary,  and  in  practically  all  cases,  so  far  as  we  are  aware,  the 
disease  has  ultimately  recurred. 

Thyroid  extract  has  also  been  used  in  inoperable  cases  of  cancer, 
either  in  conjunction  with  Beatson's  operation  or  alone.  Here  again, 
temporary  improvement  has  followed  its  use  in  some  instances,  but  in 
the  majority  of  cases,  no  effect  whatever  is  produced. 

Anodynes. — Apart  from  endeavours  to  arrest  the  spread  of  inoper- 
able cancer  the  surgeon  can  do  little  but  alleviate  pain,  which  is  often 
distressing  and  continuous.  The  most  efficacious  drug  is  morphine, 
and  the  doses  must  be  regulated  by  the  symptoms.  Once  commenced, 
it  is  often  impossible  to  discontinue  its  use,  and  it  should  not  be  com- 
menced until  all  'other  remedies  have  proved  useless.  The  neuralgic 
pains  can  often  be  relieved  by  hygienic  measures,  and  the  coal-tar  series 
of  drugs  are  often  very  valuable — for  example,  aspirin  in  fifteen-grain 
cachets,  or  phenacetin  in  doses  of  ten  grains.  A  good  formula  for  the 
latter  is : 

Phenacetin          ...  .     gr.  v-x 


Sodii  bromidi     . 
Tr.  belladonnas  . 
Mucilag.  tragacanth.  . 
Aq.  chloroform! 


gr.  x 

TTlv 

33 


ad  gj 


BENIGN  VARIETIES. — The  Myxomata  are  tumours  con- 
sisting of  embryonic  connective  tissue  in  which  are  found  the  characteristic 
branched  ramifying  cells,  and  often  also  a  large  proportion  of  the  round 
variety.  They  contain  elastic,  fibrous,  and  fatty  tissue,  and  possess  but 
few  capillary  blood-vessels.  They  are  encapsuled,  nodular,  and  soft, 
and  yield  a  gummy  mucous  fluid  on  scraping.  They  are  simple  ;  they 
do  not  tend  to  recur  if  properly  removed  ;  they  grow  in  the  fat,  in  the 
subcutaneous  and  intermuscular  tissues,  in  the  skin,  mucous  membranes, 
nerves,  salivary  glands,  etc.,  and  they  are  perhaps  most  common  in  the 
parotid  region.  They  are  slow-growing,  mobile,  semi-fluctuating,  and, 
in  the  case  of  the  nerves,  often  multiple. 


TUMOURS  OF  THE  CELLULAR  TYPE  251 

The  treatment  is  to  remove  the  myxoma  and  its  capsule,  cutting 
through  the  healthy  tissues  beyond. 

The  Fibromata  consist  of  fully  formed  connective  tissue  and  occur 
in  two  varieties — the  soft  and  the  hard.  The  soft  fibroma  is  more 
cellular  than  the  hard,  and  contains  delicate  fibrous  bundles  not  closely 
approximated.  Its  usual  seat  is  the  skin,  where  it  appears  as  molluscum 
fibrosum.  The  hard  fibroma  is  composed  of  dense  fibrous  tissue, 
showing  a  concentric  arrangement  around  the  vessels  which  are 
adherent  to  the  tumour,  and  remain  open  when  divided,  especially 
the  veins.  It  is  nodular,  whitish-grey,  creaks  under  the  knife  when 
cut,  and  contains  large  cavernous  venous  spaces.  It  occurs  wherever 
there  is  dense  connective  tissue— in  the  skin,  in  the  connective  tissues, 
especially  the  fasciae,  in  the  nerves,  periosteum,  etc.  The  fibromata  are 
simple  tumours  which  grow  slowly,  and  are  only  injurious  when  they 
press  upon  important  structures.  They  undergo  various  forms  of  de- 
generation, leading  to  calcification,  or  cystic  formation. 

Moles  are  subcutaneous  tumours  containing  a  pigment  called 
melanin.  They  are  highly  cellular  in  structure,  and  opinion  is  divided 
as  to  whether  the  cells  are  derived  from  the  deeper  layers  of  the  epithe- 
lium or  the  chromatophore  cells  of  the  true  skin.  They  may  become 
malignant,  with  rapid  metastasis  throughout  the  body.  In  some  cases 
this  may  occur  without  any  obvious  change  in  the  mole  itself. 

Treatment. — The  hard  fibromata  should  be  removed,  and  when  they 
possess  a  definite  capsule  they  may  generally  be  shelled  out  of  it  with 
ease ;  but  in  many  cases,  when  they  occur  in  connection  with  the  fasciae, 
the  capsule  is  not  well  defined,  and  it  is  necessary  to  take  away  this 
structure  along  with  them.  There  is  no  tendency  to  recurrence  after 
complete  removal.  The  pedunculated  molluscum  fibrosum  can  be  snipped 
off,  and  a  very  small  scar  is  left.  Moles  can  only  be  excised ;  they 
have  no  capsule.  In  removing  a  large  fibroma  care  must  be  taken  not 
to  cut  into  its  substance,  for  the  large  vessels  are  embedded  in  the  tumour 
and  are  unable  to  retract,  and  therefore  the  bleeding  may  be  very  severe. 
The  removal  of  fibromata  in  the  naso-pharynx  may  be  complicated  by 
the  most  alarming  and  uncontrollable  haemorrhage  if  this  precaution  be 
neglected.  If  such  an  accident  should  happen,  the  tumour  must  be 
ablated  as  quickly  as  possible,  when  the  vessels  leading  to  it  will  generally 
contract,  and  the  haemorrhage  will  cease  spontaneously;  even  if  this  be 
not  the  case,  the  bleeding  points  will  be  much  more  readily  accessible. 

The  Lipomata  are  tumours  composed  of  tissue  which  resembles 
normal  fat  and  is  arranged  in  lobules  with  connective  tissue  between. 
The  cells  are  somewhat  larger  than  normal  fat  cells.  Sometimes  the 
tumours  contain  a  considerable  quantity  of  fibrous  or  mucous  tissue,  and 
they  are  met  with  in  two  forms.  One  is  termed  the  diffuse  lipoma,  in 
which  there  is  a  diffuse  formation  of  coarse  fat  not  surrounded  by  a 
capsule  ;  it  is  usually  met  with  at  the  back  of  the  neck  on  each  side  of 


252  TUMOURS 

the  spine,  or  in  each  anterior  triangle  of  the  neck,  but  it  occurs  also 
over  the  abdomen,  the  arms,  and  elsewhere.  More  frequently,  however, 
the  lipomata  are  circumscribed,  soft,  and  lobulated  encapsuled  tumours ; 
there  is  often  only  very  delicate  tissue  connecting  the  lobules 
together.  They  are  usually  smooth  on  their  deeper  surface,  and 
when  growing  in  the  subcutaneous  tissues  they  penetrate  among  the 
fibrous  bands  connecting  the  under  surface  of  the  skin  with  the  tissues 
beneath,  so  that  the  skin  does  not  move  quite  freely  over  them.  They 
possess  a  more  or  less  well-defined  capsule,  out  of  which  they  are  readily 
shelled.  They  occur  at  all  ages  and  grow  slowly  ;  they  are  met  with  most 
frequently  in  the  subcutaneous  tissues  where  fat  is  abundant,  such  as  the 
back  of  the  neck,  the  front  of  the  thigh,  the  abdominal  wall,  the  arms, 
the  axillae,  the  buttocks,  etc. 

Treatment. — (a)  Of  the  Eneapsuled  Variety. — These  growths  are 
readily  removed,  and  shell  out  of  their  capsule  without  any  trouble,  bat 
care  must  be  taken  to  see  that  none  of  the  outlying  lobules  are  left 
behind,  as  those  left  will  grow  again  and  form  a  fresh  tumour.  The  best 
way  to  remove  a  lipoma  is  to  squeeze  up  the  tumour  forcibly  between 
the  thumb  and  forefinger  of  the  left  hand  and  make  the  skin  very  tense 
over  it.  Then,  on  incising  the  skin,  subcutaneous  tissue  and  capsule, 
the  lipoma  is  projected  forcibly  through  the  incision,  and  its  complete 
enucleation  is  insured.  When  lipomata  occur  in  parts  subject  to  pressure, 
inflammation,  leading  to  adhesions  between  the  tumour  and  the  skin 
covering  it,  or  the  structures  over  which  it  lies,  is  not  uncommon  ;  in  such 
cases  care  must  be  taken  to  remove  the  whole  of  the  tumour,  and  it  is 
generally  best  to  remove  the  adherent  skin  as  well. 

(6)  Of  the  Diffuse  Variety. — In  these  cases  the  question  of  operation 
depends  on  the  amount  of  pain  and  unsightliness  that  the  tumour  causes 
and  on  the  wishes  of  the  patient.  As  the  mass  is  not  encapsuled  it  is 
not  possible,  as  a  rule,  to  remove  the  growth  entirely,  and  therefore 
it  is  likely  to  grow  again ;  but  in  many  cases  considerable  improvement 
both  as  regards  pain  and  appearance,  can  be  effected  by  excising  as  much 
of  it  as  possible ;  in  doing  this  care  must  be  taken  to  avoid  damage  to 
important  structures,  such  as  nerves,  etc. 

Chondromata  are  tumours  consisting  essentially  of  cartilage,  of 
which  they  may  embrace  all  varieties,  including  the  ramified  cell  form 
without  capsule  usually  found  in  embryonic  conditions  and  in  some  of 
the  lower  animals.  For  the  most  part  the  cartilage  resembles  the 
normal  hyaline  variety,  but  it  differs  from  it  in  that  the  blood-vessels 
penetrate  into  the  cartilaginous  nodules.  The  tumour  is  composed  of 
an  aggregation  of  nodules  of  cartilage  separated  by  fibrous  tissue,  and 
is  encapsuled. 

Chondromata  form  rounded  or  lobulated  tumours  which  may  surround 
various  structures,  such  as  tendons,  nerves,  or  vessels,  without  actually 
destroying  them.  On  section  they  are  usually  semi-transparent,  greyish- 

BU 

' 


TUMOURS  OF  THE  CELLULAR  TYPE  253 

blue,  firm  and  elastic,  or  soft.  They  occur  especially  in  the  phalanges 
and  metatarsal  bones,  where  they  are  often  multiple ;  in  the  jaw,  in  the 
pelvis,  or  about  the  epiphyses  of  long  bones.  Sometimes  also  they  occur 
in  soft  parts,  such  as  the  parotid,  the  submaxillary  gland,  and  the 
testicle  ;  but  it  is  a  question  whether  chondromata  occurring  in  the  soft 
tissues  are  not  really  chondrifying  sarcomata  rather  than  true  chondro- 
mata. At  any  rate  these  tumours  are  generally  malignant  in  the  testicle, 
and  give  rise  to  secondary  deposits  in  the  lungs,  and  the  same  chondri- 
fication  takes  place  there.  Chondromata  may  undergo  calcification  or 
fatty  or  mucous  degeneration,  leading  to  the  formation  of  cysts.  They 
grow  slowly  and  cause  trouble  chiefly  by  pressure,  and  they  are  benign 
tumours,  with  the  exception  of  the  variety  met  with  in  the  soft  parts 
already  mentioned. 

Treatment. — When  .the  tumour  is  situated  in  the  soft  parts,  the 
best  treatment  is  extirpation  ;  the  capsule  should  be  removed  because 
of  the  possible  malignant  nature  of  the  tumour.  When  the  growth  springs 
from  a  bone,  it  may  be  sufficient  to  chip  it  away  freely,  or,  if  situated  in  the 
interior,  to  scrape  it  out  without  performing  amputation ;  this  may  be 
done  even  in  the  multiple  chondromata  of  the  fingers.  Care  must  be 
taken  to  do  this  as  completely  as  possible,  because  recurrence  is  apt  to 
take  place  from  lobules  of  the  cartilage  being  left  behind.  Should  this 
happen,  enucleation  may  be  repeated,  or  it  may  be  necessary  to  amputate 
if  the  bone  be  so  much  destroyed  by  the  growth  as  to  be  useless,  as  may 
be  the  case  in  a  phalanx,  for  example. 

The  Osteomata  are  composed  of  bony  tissue,  and  are  met  with  in 
two  chief  forms.  The  rarer  of  these  is  the  hard  or  ivory  osteoma  or 
exostosis,  which  is  a  flat  sessile  bony  mass  chiefly  occurring  on  the  vertex 
of  the  skull,  on  one  of  the  bones  of  the  face,  or  in  the  external  auditory 
meatus  ;  it  is  of  ivory  hardness,  and  is  formed  of  dense  compact  bone, 
containing  lacunae  and  canaliculi,  but  without  proper  Haversian  canals. 
The  other  form  is  the  spongy  exostosis,  which  resembles  cancellous  bone 
in  structure  and  generally  arises  in  the  neighbourhood  of  the  epiphyseal 
lines.  During  the  period  of  growth  these  spongy  exostoses  are  covered 
with  a  layer  of  cartilage,  and  it  is  from  this  part  of  the  tumour  that 
growth  takes  place.  As  a  rule  this  cartilage  quickly  ossifies  at  the 
point  where  the  tumour  joins  the  bone  from  which  it  arises,  and  then 
growth  ceases  there  whilst  it  goes  on  at  the  periphery  of  the  tumour ; 
hence  these  growths  are  usually  pedunculated,  and  they  vary  in  size  and 
are  nodular  on  the  surface. 

Treatment. — The  treatment  of  the  spongy  exostoses  is  to  cut 
through  their  base  and  remove  them ;  if  this  be  done  where  growth  has 
ceased  and  cartilage  does  not  exist,  recurrence  will  not  take  place.  Before 
antiseptic  treatment  was  employed,  many  patients  developed  a  suppura- 
tive  osteomyelitis  after  operation,  and  either  died  or  had  to  lose  the  limb  ; 
great  care  must  be  taken  in  the  aseptic  management  of  the  wound. 


254  TUMOURS 

The  small  ivory  exostoses  on  the  outside  of  the  skull  are  seldom  of 
sufficient  size  to  require  operation.  Their  removal  is  always  difficult 
and  dangerous  because,  owing  to  their  density,  the  force  required  to 
chip  them  off  sometimes  fractures  the  skull.  Hence  it  is  best  to  leave 
them  alone  as  a  rule,  but,  should  they  press  on  the  eye,  ear,  or  other 
important  parts,  or  grow  internally,  it  may  be  necessary  to  undertake 
their  removal.  If  the  growth  be  small,  it  may  be  possible  to  encircle 
the  tumour  by  a  large  trephine,  and  the  exostosis  and  the  base  from 
which  it  springs  can  be  removed  entire  by  cutting  through  normal  bone 
all  around.  In  the  larger  growths  this  is  impossible,  however,  and  the 
best  way  of  removing  them  is  to  drill  a  number  of  holes  through  the  base 
of  the  tumour  with  a  dental  drill,  and  then  to  join  these  together  with  a 
saw  and  thus  complete  the  removal ;  in  the  ear  it  is  sometimes  possible  to 
break  them  off  by  means  of  a  sudden  smart  tap,  after  their  base  has  been 
drilled.  If  the  growth  be  very  diffuse,  and  must  be  removed,  it  may 
require  more  than  one  operation  for  its  satisfactory  treatment. 

Bony  growths  which  do  not  properly  come  under  the  heading  of 
osteoma  are  also  met  with  elsewhere  ;  among  these  may  be  mentioned 
the  bony  growths  which  occur  from  irritation  in  the  adductors  of  the 
thigh  in  riders,  or  in  the  deltoid  muscle  in  soldiers  ;  they  are  dealt  with  in 
connection  with  the  affections  of  muscles. 

TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES. 

Amongst  the  tumours  composed  of  more  complex  tissues  are  those 
consisting  of  muscular  tissue  or  myomata,  of  nerve  tissue  or  neuromata, 
of  blood-vessels  or  angiomata,  of  lymphatic  vessels  or  lymphangiomata, 
and  complex  tumours  and  cysts. 

Myomata  are  composed  of  unstriped  muscular  fibre,  and  are  met 
with  where  unstriped  muscular  fibre  is  normally  present — e.g.  in  the 
uterus,  the  prostate,  the  wall  of  the  oesophagus,  the  stomach,  and  the 
intestines.  In  the  latter  situation  they  generally  project  into  the  lumen 
of  the  gut,  forming  pedunculated  polypi,  covered  by  the  mucous  mem- 
brane. Myomata  may  be  single,  but  they  are  more  often  multiple  ;  they 
form  round  lobulated  tumours  with  an  investing  fibrous  capsule,  and  on 
section  they  resemble  fibromata  except  that  they  are  of  a  purplish  colour. 
They  are  generally  very  vascular,  especially  at  the  periphery,  where  large 
venous  sinuses  are  numerous.  They  occur  in  adults,  and  cause  trouble 
from  their  size  and  their  tendency  to  bleed. 

Treatment. — This  depends  mainly  upon  their  situation,  and  the  con- 
sideration of  the  treatment  must  therefore  be  considered  in  connection 
with  the  particular  organs  in  which  they  occur. 

Neuromata  are  composed  of  nerve  tissue  and  are  very  rare,  if,  indeed, 
they  ever  occur ;  the  tumours  generally  spoken  of  as  neuromata  are 
inflammatory  thickenings  occurring  in  the  course  of  nerves,  such,  for 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES    255 

example,  as  the  enlargements  at  the  divided  ends  or  tumours,  such  as 
myxomata,  fibromata,  or  sarcomata,  occurring  in  the  neighbourhood  of 
and  involving  nerves.  In  connection  with  neuromata  may  be  men- 
tioned the  gliomata,  which  occur  in  the  central  nervous  system,  and  in 
the  retina,  and  are  composed  of  neuroglia.  They  are  often  vascular, 
and  as  a  rule  they  are  not  malignant  except  locally  ;  the  gliomata 
which  occur  in  connection  with  the  retina  are  more  malignant,  however, 
and  possibly  ought  to  be  included  among  the  sarcomata. 

The  treatment  of  neuromata  belongs  to  that  of  the  affections  of 
nerves.  A  glioma  should  be  removed  whenever  possible ;  the  subject 
is  dealt  with  in  connection  with  tumours  of  the  brain. 

Angiomata  or  naevi  are  composed  of  vascular  tissue,  and  the  essential 
element  in  them  is  the  formation  of  blood-vessels.  The  latter  are  partly 
of  new  formation  and  are  partly  pre-existing  vessels  much  dilated  and 
thickened.  These  tumours  are  divided  into  two  groups — the  simple  or 
capillary,  and  the  cavernous  or  venous. 

In  the  capillary  angioma  the  vessels  are  distinct  and  have  well- 
defined  walls,  and  the  tumour  consists  of  a  mass  of  dilated  tortuous 
capillaries,  derived  not  only  from  dilatation  of  old  capillaries,  but  also 
from  the  formation  of  new  ones.  There  is  no  definite  capsule,  and 
therefore  the  tumours  are  not  clearly  marked  off  from  the  surrounding 
tissues,  their  outline  being  irregular  and  somewhat  lobulated.  They 
occur  usually  in  the  skin,  and  may  be  either  upon  its  free  surface  or  in 
its  substance,  and  they  may  spread  from  the  skin  to  the  subcutaneous 
tissue.  The  tumour  generally  presents  a  bright  red  colour,  but  it  may  be 
somewhat  bluish  where  the  circulation  is  slow. 

The  cavernous  angioma,  or  venous  naevus,  occurs  in  the  skin,  sub- 
cutaneous tissue,  muscles,  etc.,  and  is  made  up  of  large  spaces  communi- 
cating with  the  blood-vessels  and  separated  from  each  other  by  septa 
of  unequal  thickness  containing  fibrous  tissue,  remains  of  the  original 
tissue,  elastic  fibres,  striped  and  unstriped  muscle,  fat  cells,  vasa  vasorum, 
lymphatics,  and  nerves,  the  blood  spaces  themselves  being  lined  with 
endothelium.  The  great  majority  of  these  venous  naevi  are  congenital 
(in  fact  both  kinds  of  naevi  generally  are),  and  they  may  disappear  as 
the  child  grows  older,  or  they  may  increase  in  size  ;  the  latter  is  more 
frequently  the  case  with  the  subcutaneous  or  cavernous  form.  Naevi 
sometimes  undergo  cystic  degeneration,  the  communication  between 
the  blood  spaces  and  the  vessels  being  obliterated,  and  the  former  then 
undergoing  dilatation,  so  that  cysts  of  variable  size  are  formed. 

Treatment. — The  treatment  of  naevi  may  be  divided  into  (i)  excision, 
and  (2)  the  use  of  methods  which  aim  at  setting  up  inflammation  in  the 
vessels  so  as  to  procure  first  thrombosis  and  ultimately  atrophy  of  the 
vascular  growth. 

Excision. — Excision  is  certainly  the  best  possible  method  of  treat- 
ment, and  should  be  adopted  in  all  cases  where  it  is  possible  to  carry 


256  TUMOURS 

it  out.  It  presents  the  following  great  advantages  over  all  other  methods. 
It  is  certain  and  rapid  in  its  results,  the  affection  being  cured  permanently 
within  a  fortnight ;  there  is  no  pain  attending  the  after-treatment  ;  no 
frequent  change  of  dressings  is  called  for,  and  therefore  there  is  not  the 
liability  to  septic  infection  which  is  almost  inevitable  where  the  opposite 
is  the  case.  The  cases  most  frequently  met  with  in  practice  are  the 
moderate-sized  capillary  naevi,  with  or  without  affection  of  the  sub- 
cutaneous structures,  and  this  form  is  certainly  best  treated  by  enclosing 
it  in  an  oval  incision  well  free  of  the  growth  and  cleanly  excising  it.  A 
large  nsevus  may  not  be  suited  for  excision  either  because  its  size  renders 
the  operation  formidable  from  loss  of  blood,  as  may  be  the  case  in  infants, 
or  because  there  may  be  difficulty  in  bringing  the  edges  of  the  wound 
together.  In  the  former  case  it  is  advisable  to  adopt  one  of  the  methods 
described  below  for  procuring  thrombosis,  and  when  enough  of  the 
tumour  has  thus  been  obliterated  the  rest  may  be  excised.  In  the  latter 
case  most  superficial  naevi  can  be  satisfactorily  treated  by  excision  followed 
by  undermining  of  the  skin  so  as  to  secure  apposition  of  the  cut  edges. 
When  the  area  is  too  extensive  for  this,  Thiersch's  skin  grafting  is  pre- 
ferable to  the  scarring  that  inevitably  follows  other  methods.  Even 
on  exposed  parts  the  scar  left  by  the  operation  is  not  so  noticeable  as  that 
which  results  from  other  modes  of  treatment.  A  superficial  naevus  will 
rarely  be  found  too  extensive  for  treatment  by  excision,  especially  if 
Thiersch's  grafting  be  employed  ;  several  partial  operations  may  be 
required. 

When  the  surgeon  has  to  deal  with  a  deep-seated  cavernous  naevus, 
which  is  fairly  limited  and  does  not  involve  any  important  structure, 
complete  excision  should  also  be  attempted.  There  is  no  particular 
danger  in  excising  a  naevus.  It  should  be  done  strictly  antiseptically,  and 
if  care  be  taken  to  cut  well  beyond  the  tumour,  there  is  no  bleeding  of 
importance,  the  vessels  actually  dilated  being  those  within  the  growth 
itself ;  those  that  are  divided  in  the  operation  are  merely  the  isolated 
afferent  and  efferent  trunks,  which  are  easily  secured  as  they  are  cut. 
It  is  important  not  to  cut  into  the  growth,  as  otherwise  the  haemorrhage 
may  be  profuse  and  controlled  only  with  the  utmost  difficulty.  When, 
however,  the  naevus  is  partly  superficial  and  partly  deep,  involving 
structures  which  cannot  be  readily  removed,  such  as  the  lip,  or  even 
more  important  deeper  structures,  then  excision  is  not  advisable,  and 
other  methods  must  be  employed. 

Electrolysis. — In  using  electrolysis  for  naevi,  different  effects  are 
produced  by  the  positive  and  negative  poles  ;  at  the  positive  pole  a 
firm,  hard,  and  readily  organised  clot  forms,  whilst  at  the  negative  it  is 
soft  and  frothy,  and  of  little  value  in  the  formation  of  new  tissue.  Hence 
it  is  the  positive  pole  which  is  chiefly  relied  upon  to  produce  the  local 
effect.  Several  needles  connected  with  this  pole  should  be  introduced  into 
the  swelling  at  various  points,  especially  in  the  neighbourhood  of  the 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES    257 

veins  which  leave  it.  The  needles  should  be  insulated  by  means  of 
shellac  or  guttapercha,  or  some  similar  material,  right  up  to  within  a 
quarter  of  an  inch  of  the  point,  and  should  be  pushed  into  the  nsevus 
until  the  insulated  portion  lies  in  the  hole  in  the  skin.  If  the  needle  be 
not  properly  insulated  where  it  passes  through  the  skin  it  will  produce  a 
slough,  which  will  not  only  leave  a  scar,  but  may  also  be  a  point  of  entrance 
for  septic  material  into  the  clot.  Care  must  be  taken  that  the  points  of 
the  needles  do  not  approach  too  near  the  surface  of  the  tumour,  whether 
it  be  skin  or  mucous  membrane,  for,  even  if  they  do  not  actually  perforate 
it,  they  may  lead  to  sloughing  and  subsequent  sepsis  ;  this  is  particularly 


FIG.  60. — METHODS  OF  INSERTING  THE  NEEDLES  IN  ELECTROLYSIS  OF  A  N^EVUS. 
In  the  upper  figure  the  needles  are  parallel,  and  the  current  is  evenly  diffused  over  a  large 
area  ;  this  is  the  correct  method.  In  the  lower  figure  the  current  becomes  concentrated 
at  the  centre  of  the  tumour,  which  is  therefore  liable  to  slough.  The  periphery  is  hardly 
acted  upon  at  all.  (Lewis  Jones.) 

likely  to  happen  if  the  points  of  several  needles  be  close  together.  If  more 
than  one  needle  be  introduced  into  the  naevus,  care  should  be  taken  to 
keep  them  parallel  to  each  other,  so  as  to  ensure  equable  diffusion  of  the 
current  and  avoid  sloughing  (see  Fig.  60).  A  useful  and  ingenious  handle 
has  been  suggested  by  Dr.  Lewis  Jones  for  this  purpose  (see  Fig.  61). 
By  its  means  the  needles  are  kept  parallel,  while  both  positive  and  negative 
electrodes  can  be  inserted  into  the  tumour  if  desired.  The  needles  should 
be  rendered  aseptic  by  boiling  ;  it  is  well  not  to  immerse  them  in  strong 
carbolic  lotion,  as  that  destroys  the  insulating  material,  and,  if  steel 
needles  are  used,  an  immersion  in  a  I  in  500  perchloride  solution  would 
damage  the  metal.  As  a  rule  platinum  needles  are  to  be  preferred  ;  the 
only  drawback  is  that  it  is  impossible  to  get  a  good  sharp  point  to  them. 
An  alcoholic  solution  of  shellac  should  be  at  hand  with  which  the  needles 
can  be  painted  to  renew  any  of  the  insulation  that  has  become  faulty. 


258 


TUMOURS 


It  is  especially  necessary  to  see  to  this  if  steel  needles  be  used,  as  a  per- 
manent black  mark  is  liable  to  occur  if  any  uninsulated  portion  lies  in  con- 
tact with  the  skin.  After  the  needles  attached  to  the  positive  pole  have 
been  inserted  in  the  manner  just  described,  a  large  flat  pad  attached  to 
the  negative  pole  and  moistened  with  salt  solution  is  placed  on  the  skin 
either  over  the  spine  or  somewhere  in  the  neighbourhood  of  the  naevus. 
The  pad  must  be  moved  from  one  point  to  another  as  the  electrolysis 
proceeds,  so  that  it  shall  not  act  too  long  at  one  spot ;  if  it  does,  a  slough 
may  result.  In  large  naevi  both  poles  may  be 
buried  in  the  tumour,  the  negative  pole  being 
attached  to  a  single  needle  insulated  as  described 
above,  which  is  also  pushed  into  the  swelling.  For 
this  purpose  the  handle  figured  below  (see  Fig. 
61)  is  specially  useful.  The  strength  of  the 
current  should  be  from  20  to  30  milliamperes, 
but,  when  three  or  four  needles  are  used,  30  to 
40  may  be  used.  The  current  should  be  continued 
for  about  ten  minutes  ;  the  best  criterion  as  to 
when  to  discontinue  it  is  perhaps  that  the  naevus 
is  felt  to  become  firm.  Before  withdrawing  the 
needles,  the  current  should  be  reversed  for  a  few 
seconds,  as  otherwise  those  connected  with  the 
positive  pole  adhere  firmly  to  the  tissues,  and 
bleeding  results  from  their  withdrawal ;  this  is, 
however,  not  of  any  real  moment,  light  pressure 
being  sufficient  to  check  it. 

The  skin  should  be  thoroughly  disinfected 
before  the  operation  (see  p.  100),  and  after  it  a 
little  salicylic  wool  may  be  applied  over  the  punc- 
ture, fixed  on  with  collodion,  and  allowed  to 
remain  till  healing  has  taken  place.  The  elec- 
trolysis causes  a  good  deal  of  pain,  especially 
at  the  make  and  break  of  the  current,  and  when 
its  strength  is  increased,  and  it  is  therefore  well  to  employ  a  general 
anaesthetic.  The  current  should  be  increased  very  gradually,  and  when 
the  operation  is  completed  it  should  be  diminished  gradually  and 
not  shut  off  abruptly,  as  otherwise  considerable  shock  may  be  caused. 
Similarly,  before  reversing  the  current,  its  strength  should  be  de- 
creased gradually  almost  to  nothing.  When  the  naevus  is  situated 
over  the  fontanelle  of  a  young  infant,  a  watch  must  be  kept  on  the  pulse 
as  the  current  is  increased.  If  any  sign  of  shock  be  noticed,  the 
current  must  be  diminished  or  shut  off  entirely. 

As  the  result  of  the  electrolysis  the  naevus  becomes  hard,  and  this 
hardness  may  sometimes  last  several  weeks  before  it  disappears  entirely. 
If  the  naevus  be  of  any  size,  one  sitting  is  rarely  sufficient  for  a  cure, 


FIG.  61. — BIPOLAR  FORK 
ELECTRODE.  The  needles  are 
alternately  positive  and  neg- 
ative, and  are  screwed  in. 
The  smaller  figure  shows  the 
method  of  insulation.  (Lewis 
Jones.) 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES     259 

and  therefore  the  application  is  repeated  as  soon  as  the  hardness  has 
subsided  sufficiently  to  show  what  portion  requires  further  treatment  ; 
at  first  this  may  be  done  at  intervals  of  three  weeks.  After  three  or 
four  sittings,  however,  the  greater  part  of  the  naevus  will  have  become 
firm,  and  then  longer  intervals  must  be  allowed,  because  it  is  impossible 
to  judge  how  much  remains  to  be  done  until  the  hardness  has  almost 
disappeared. 

Electrolysis  may  be  conveniently  combined  with  temporary  strangula- 
tion of  the  blood-vessels  of  the  part,  especially  in  naevus  of  the  lip.  After 
the  patient  has  been  anaesthetised  the  special  forceps  shown  in  Fig.  62 
are  applied  to  the  lip,  as  shown  in  Fig.  63,  so  as  to  obstruct  circulation 
through  the  naevus  completely.  The  blades  of  the  forceps  should  be 
covered  with  india-rubber,  not  only  because  this  renders  them  less  likely 
to  injure  the  tissues,  but  because  there  is  a  risk  of  a  serious  burn  followed 


FIG.  62. — COMPRESSION  FORCEPS  FOR  USE  IN  ELECTROLYSIS  OF  N^EVUS  OF  THE  Lip. 


by  troublesome  sloughing  if  the  forceps  come  into  contact  with  either  of 
the  connecting  wires.  After  the  forceps  have  been  applied,  the  naevus 
is  electrolysed  in  the  ordinary  manner  with  several  platinum  needles, 
which  may  be  connected  to  one  or  both  poles  of  the  battery.  After 
five  to  ten  minutes  the  circuit  is  broken,  but  the  forceps  are  left  on  for 
another  five  or  ten  minutes.  By  this  means  the  coagulum  around  the 
electrodes  spreads  throughout  the  vascular  channels  near  it,  and  is  not 
washed  away  into  the  general  circulation.  A  greater  effect  can  thus  be 
got  than  by  simple  electrolysis  ;  weaker  currents  can  be  employed,  with 
a  correspondingly  smaller  risk  of  sloughing.  For  a  very  small  naevus 
it  is  sometimes  possible  to  use  an  ordinary  pair  of  tongue  forceps  or  a 
couple  of  intestinal  clamps,  but  the  blades  must  always  be  insulated  with 
india-rubber.  In  other  situations  the  same  principle  may  be  employed. 
In  the  case  of  a  naevus  situated  over  a  bone — for  example,  on  the  forehead 
— a  firm  india-rubber  ring  held  securely  in  position  by  tapes  tied  at  the 
back  of  the  neck  answers  the  purpose  very  well. 

Caustics. — Besides  the  extensive  and  important  naevi,  there  are  small 
superficial  capillary  stains,   of  small  size  and  insignificant  proportions, 


260 


TUMOURS 


in  which  it  is  not  worth  while  to  have  recourse  to  excision.  The  par- 
ticular method  to  be  employed  will  depend  to  a  great  extent  on  the 
size  and  situation  of  the  tumour.  When  there  is  a  superficial  naevus 
affecting  only  the  surface  of  the  skin,  the  application  of  an  irritant  will 
suffice.  The  most  popular  is  the  solution  of  ethylate  of  sodium  (one  part 
to  eight  of  ethylic  alcohol),  which  is  painted  over  the  part  once  a  day  for 
three  or  four  days,  and  which  usually  gives  rise  to  sufficient  inflammation 
without  causing  marked  scarring.  It  causes  a  little  pain  at  the  time 
of  application,  but  this  passes  off  immediately ;  no  dressing  is  required. 
The  small  crust  that  forms  after  the  application  is  allowed  to  dry  up 


FIG.  63. — METHOD  OF  TREATING  N^EVI  BY  COMPRESSION  AND  ELECTROLYSIS. 
Drawn  from  a  photograph. 

and  drop  off,  when  the  naevus  will  be  found  to  be  cured  if  the  application 
has  been  sufficient ;  the  application  may  be  repeated  should  any  of  the 
naevus  tissue  remain.  Nitric  acid  is  sometimes  used,  but  it  leaves  a 
distinct  scar  and  is  decidedly  painful  both  at  the  time  of  application  and 
subsequently. 

A  good  method  of  treatment  for  very  tiny  naevi  or  red  points  is  to 
draw  through  them  a  needle  armed  with  a  very  fine  silk  thread  which 
has  been  dipped  in  liquefied  carbolic  acid.  The  skin  all  around  where 
the  needle  enters  should  be  smeared  with  sterilised  vaseline,  so  that  the 
thread  does  not  come  into  contact  with  it,  as  otherwise  it  would  cause  a 
burn  and  give  rise  to  a  scar.  The  thread  is  pulled  right  through  the 
naevus,  and  then  pressure  is  applied  for  a  little  until  the  bleeding  stops, 
and  the  puncture  is  covered  with  collodion.  The  old  method  of  vaccinat- 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES    261 


ing  upon  these  minute  naevi  is  a  good  one  if  they  be  small,  superficial, 
and  in  a  suitable  situation. 

The  Actual  Cautery. — This  is  preferable  to  the  use  of  chemical 
caustics  in  the  majority  of  cases,  and  yields  very  satisfactory  cosmetic 
results  on  the  whole  when  it  is  desired  to  obliterate  a  small  spider 
naevus  with  a  central  red  spot  from  which  a  number  of  small  vessels 
radiate  in  stellate  fashion.  When  the  naevus  is  situated  upon  the  face 
the  patient  should  be  placed  in  such  a  position  that  the  surgeon  has 
complete  control  of  the  head, 
so  that  if  the  child  moves 
there  is  no  risk  of  cauterising 
normal  tissues.  The  head  is 
steadied  between  the  surgeon's 
wrists  so  that  his  hands  and 
the  patient's  head  move  to- 
gether, and  a  fine  electro- 
cautery  heated  almost  to  white- 
ness is  plunged  rapidly  into 
the  centre  of  the  naevus  and 
withdrawn  immediately.  There 
is  no  need  to  administer  an 
anaesthetic  to  these  cases,  as 
the  pain  is  momentary  and 
quite  slight.  The  puncture  can 
be  sealed  with  a  drop  of  col- 
lodion or  friar's  balsam. 

More  extensive  naevi  require 
the  administration  of   an  anaes- 
thetic.      In     these    cases     the 
cautery  should  be  at  a  dull  red 
heat  and  should  be  thrust  com- 
pletely    through     the     naevus. 
When    naevi   treated    thus    are 
situated  over   important  struc- 
tures— e.g.  a  naevus  of  the  eyelid— it  is  important  that  the  point  of  the 
cautery  should  not  penetrate  too  deeply.     To  obviate  this,  the  ski 
containing  the  naevus  may  be  pinched  up  between  the  left  thumb  and 
forefinger  so  as  to  draw  the  naevus  away  from  the  subjacent  structures. 
It  is  easy  to   ascertain   when    the    cautery   has  passed  through  the 
dermis,    as  this   structure   offers    a   definite    resistance    which    cease 
suddenly   as    penetration    occurs.      The   cautery  punctures   should 
about  a  quarter  of  an  inch  apart  over  the  whole  surface  of  the  naevus 
care  being  taken  to  destroy  any  vessels  that  can  be  seen  entering  . 
leaving  it.     If  the  naevus  be  too  extensive  for  the  punctures  to  b 
all  over  its  surface,  they  should  be  made  around  its  margin,  especially  at 


FIG.  64. — MULTIPLE  N^vi  IN  COURSE  OP  TREAT- 
MENT BY  THE  GALVANO-CAUTERY.  Towards  the  um- 
bilicus complete  cicatrisation  of  the  nsevus  has  been 
obtained.  Further  down  on  the  abdominal  wall 
another  nsevus  shows  the  punctate  cicatrices  caused 
by  the  first  application  of  the  cautery. 


262 


TUMOURS 


the  points  where  the  growth  seems  to  be  most  active.  The  best  dressing 
for  these  cases  is  friar's  balsam  painted  directly  on  to  the  surface  of  the 
naevus  ;  a  thin  layer  of  wool  is  then  applied  and  some  more  of  the  balsam 
painted  on.  The  dressing  will  fall  off  in  about  ten  days  and  the  punctures 
will  be  found  healed.  At  this  stage  the  naevus  presents  a  speckled 
appearance,  with  white  or  pinkish  spots  scattered  over  its  bright  red 
surface.  At  the  second  operation  another  series  of  punctures  is  made 
between  the  first,  and  the  process  is  continued  until  the  whole  of  the  naevus 
has  become  converted  into  scar  tissue.  This  method  is  particularly 
applicable  where  an  excision  of  a  wide  area  of  skin  is  inadvisable— e.g. 

when  a  naevus  nearly  encircles  a 
limb,  lies  over  a  joint,  or  is  in  the 
neighbourhood  of  the  eyelids.  Little 
contraction  is  caused,  the  resulting 
scar  being  often  only  slightly  larger 
than  the  original  naevus. 

Freezing.  —  This  method  has 
only  been  introduced  recently.  Al- 
though there  is  usually  a  certain 
amount  of  tissue  destruction,  the 
efficacy  of  the  method  depends 
upon  the  reaction  which  follows 
the  freezing,  and  thus  differs  from 
the  effect  of  the  actual  cautery. 
Liquid  air  is  often  employed  for 
the  freezing,  but  it  is  difficult  to 
store  and  not  very  manageable  in 
use.  Probably  the  best  agent  is 
solid  carbonic  acid,  which  can  be 
obtained  in  the  form  of  a  solid 
stick  and  can  be  cut  to  any  shape. 

This  has  the  additional  advantage  that  pressure  can  be  combined 
with  extreme  cold  (  —  79°  C.).  The  carbonic  acid  can  be  purchased 
as  a  liquid  in  the  large  cylinders  used  for  the  preparation  of  mineral 
waters ;  on  opening  the  tap  of  the  cylinder  the  liquid  carbonic  acid 
escapes,  and  evaporates  so  quickly  that  intense  cold  is  produced,  which 
freezes  the  liquid  into  a  soft  snow. 

A  simple  method  of  preparing  the  solid  stick  is  described  by  Morton. 
A  huckaback  towel  is  rolled  round  a  wooden  ruler,  and  the  latter  is  with- 
drawn from  the  tube  of  towelling,  which  is  destined  to  act  as  a  mould 
for  the  carbonic-acid  stick,  and  one  end  of  the  tube  is  closed  by  a 
loosely  fitting  cork.  The  gas  cylinder  is  placed  upon  a  table  with  the 
delivery  pipe  pointing  downwards,  and  the  foot  of  the  cylinder  raised 
about  six  inches  so  as  to  allow  the  liquid  contents  to  flow  towards 
the  tap ;  the  open  end  of  the  towel  mould  is  then  placed  over  the 


FIG.  65. — METHOD    OF    APPLYING     THE     SOLID 
STICK  OF  CARBON  DIOXIDE. 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES     263 

delivery  pipe  and  bandaged  firmly  in  position.  The  bandage  must  be 
carried  round  the  whole  length  of  the  tube,  then  lengthwise  along  the 
tube  round  the  outlet  valve  of  the  cylinder  and  over  the  cork  so  as  to 
prevent  the  tube  being  blown  off ;  two  or  three  bandages  are  necessary. 
The  stopcock  is  now  opened  and  the  carbonic  acid  allowed  to  escape 
fairly  rapidly,  the  towel  tubing  and  the  cork  forming  a  mould  in  which 
the  loose  carbonic-acid  snow  is  compacted  into  a  firm  cylinder,  the  porous 
towel  and  bandage  allowing  excess  of  gas  to  escape  and  preventing  an 
explosion.  After  the  gas  has  been  running  freely  for  about  a  minute  or 
a  minute  and  a  half,  the  stopcock  is  closed.  The  brass  cock  has  become 
intensely  cold,  and  any  attempt  to  handle  it  with  the  bare  hands  will 
produce  severe  frostbite.  A  pair  of  gas  tongs  or  a  thickly  folded  duster 
should  therefore  be  used.  The  bandage  is  now  removed  and  the  towel 
unrolled.  With  a  little  practice  it  will  be  found  possible  to  prepare  a 
solid  cylinder  of  carbonic  acid  six  inches  long  and  about  three-quarters 
of  an  inch  in  diameter,  sufficiently  firm  to  be  cut  to  any  shape.  This 
cylinder  must  not  be  handled  with  the  bare  hands,  but  a  couple  of  thick- 
nesses of  lint  or  a  folded  towel  are  quite  sufficient  to  protect  the  operator. 

The  end  of  the  cylinder  is  pared  so  that  its  cross-section  is  a  little 
larger  than  the  area  of  the  naevus  to  be  treated  and  is  pressed  firmly 
on  to  the  surface  of  the  naevus  and  kept  in  position  for  from  twenty  to 
forty  seconds.  On  removing  the  stick  a  deep  sharply-cut  depression 
is  seen  in  the  midst  of  a  white  frozen  area.  In  a  few  seconds  the  tissues 
thaw  and  the  depression  becomes  obliterated.  No  anaesthetic  is  needed 
for  this  procedure ;  the  actual  application  is  almost  painless,  although 
subsequently  there  is  some  slight  burning  pain  in  the  part.  After  freez- 
ing, a  sharp  reaction  takes  place  in  the  part,  accompanied  by  distinct 
blistering  or  even  slight  superficial  ulceration,  but  no  after-treatment 
is  required  beyond  a  simple  dusting  powder.  This  method  is  parti- 
cularly suitable  for  superficial  naevi  and  port-wine  marks.  It  can  also 
be  used  for  warts  and  small  cutaneous  tumours.  The  stick  of  carbonic 
acid  can  be  kept  exposed  to  the  air  for  about  a  couple  of  hours ;  if  it 
be  desired  to  preserve  it  longer  it  may  be  slipped  into  an  ordinary 
Thermos  bottle,  the  neck  of  which  is  plugged  loosely  with  cotton-wool. 

When  only  a  few  cases  have  to  be  treated,  a  stick  of  solid  carbonic 
acid  can  be  prepared  rapidly  in  the  cylindrical  moulds  provided  with  a 
cap  and  a  piston  which  are  sold  for  the  purpose.  The  carbonic-acid 
snow  is  collected,  either  in  a  tubular  wash-leather  bag  provided  with 
clips,  which  can  be  undone  so  as  to  throw  the  whole  bag  widely  open, 
or,  failing  this,  in  a  loose  bag  made  by  wrapping  an  ordinary  towel  around 
the  outlet  pipe  of  the  cylinder.  The  snow  is  then  put  into  the  cylindrical 
mould  and  compacted  together  with  the  piston  rod.  Snow  is  added  in 
small  quantities  and  hammered  down  into  the  mould  by  the  piston 
until  a  sufficient  quantity  has  been  obtained,  when,  by  taking  off  the  cap, 
the  stick  can  be  readily  forced  out  of  the  mould  with  the  piston. 


264  TUMOURS 

Radium  has  also  been  found  effectual  for  port-wine  stains,  but 
a  considerable  quantity  and  a  long  exposure  are  required. 

Lympriangiomata  are  tumours  composed  of  lymphatic  vessels  of 
new  formation,  and  it  is  often  very  difficult  to  differentiate  them  from 
lymphangiectases  or  varicose  lymphatics  ;  they  are  congenital  circum- 
scribed tumours.  Three  varieties  are  described  : 

(1)  The  simple  lymphangiomata  consist  of  dilated  lymphatic  vessels 
of  the  size  of  capillary  blood-vessels  ;   tumours  of  this  nature  occur  in  the 
perineum,  in  the  sacral  region,  in  the  axilla,  etc.     In  some  cases  the 
dilated  vessels  are  considerably  larger,  as  is  seen  in  the  tongue  in  one 
form  of  macroglossia,  and  also  in  the  lips,  where  it  goes  by  the  name  of 
macrocheilia. 

(2)  Cavernous  lymphangiomata    are    spongy    masses  composed  of 
lymphatic  vessels,  very  closely  resembling  venous  naevi  in  structure. 
They  are  found  in  the  neck,  in  the  sacral  region,  the  lips,  etc.,  generally 
in  the  subcutaneous  tissues,  but  often  deeper. 

(3)  Cystic  lymphangiomata  are  congenital  agglomerations  of  cysts 
of  various  sizes  which  may  or  may  not  communicate  with  each  other  or 
with  lymphatic  vessels.     They  are  seen  most  frequently  in  the  neck, 
where  they  have  received  the  name  of  hydrocele  of  the  neck  ;    they  are 
also  met  with  in  the  perineum,  buttocks,  thorax,  etc. 

Treatment. — Operative  interference,  such  as  excision,  used  to  be 
followed  by  suppuration  in  the  lymph  spaces,  followed  by  very  serious 
results.  This  risk  can  be  easily  avoided  nowadays  by  care  in  the  manage- 
ment of  the  wound.  In  the  majority  af  cases  electrolysis  is  the  best  treat- 
ment (see  p.  256).  In  the  cystic  forms,  injections  of  iodine  or  undiluted 
carbolic  acid  are  employed  in  the  same  way  as  for  hydrocele  of  the  tunica 
vaginalis.  In  the  smaller  forms  excision  is  frequently  practised,  but 
great  care  must  be  taken  to  ensure  the  asepticity  of  the  wound. 

Lymphadenoma. — The  causation  of  this  disease  is  still  uncertain 
and  many  authorities  consider  that  it  is  allied  to  true  tumour  forma- 
tion. It  may,  however,  be  an  infective  disorder  and  will  be  described 
in  the  section  devoted  to  diseases  of  the  lymphatic  glands  (see 
Vol.  II.). 

Lyrriplio-sarcoinata  are  composed  of  lymphatic  tissue,  and 
occur  primarily  in  glands  or  in  parts  where  lymphatic  tissue  is  normally 
found ;  they  present  a  delicate  reticulum  with  round  cells  entangled  in 
it.  The  typical  lympho-sarcoma  is  a  very  malignant  tumour  indeed. 
It  occurs  generally  in  the  neck  or  the  axilla,  and  the  growth  soon  spreads 
beyond  the  gland  capsule  and  infiltrates  the  tissues  around.  Adhesion 
to  the  surrounding  structures  soon  occurs,  and  thus  a  nodular  mass  is 
formed  composed  of  a  multitude  of  glands  united  by  adenoid  tissue. 
Other  groups  of  glands  soon  become  involved  and,  in  addition,  tumours 
composed  of  lymphatic  tissue  may  appear  in  parts  where  this  is  not 
normally  present,  as  for  example  in  bones.  The  disease  goes  on  and  is 


TUMOURS  COMPOSED  OF  MORE  COMPLEX  TISSUES     265 

accompanied  by  increasing  pallor  of  the  patient,  but  not  at  first  by 
emaciation.  Ultimately  death  takes  place  from  exhaustion. 

Treatment. — The  treatment  of  lympho-sarcoma  is  unsatisfactory. 
Excision  of  a  mass  of  lympho-sarcomatous  glands  seldom  arrests  the 
progress  of  the  disease,  even  though  the  whole  of  the  affected  area  may 
apparently  be  removed.  Other  glands  soon  enlarge,  and  recurrence  often 
takes  place  in  the  neighbourhood  of  the  primary  growth.  Hence,  except 
at  a  very  early  stage,  or  where  its  situation  is  such  that  the  growth  causes 
much  suffering  from  pressure  upon  important  organs,  excision  cannot  be 
recommended  ;  even  at  an  early  stage  it  is  of  doubtful  value. 

Cysts. — This  is  perhaps  the  best  place  to  refer  to  the  various  forms 
of  cysts  ;  the  true  cysts  are  those  of  new  formation,  and  are  not  produced 
by  obstruction  of  pre-existing  canals  or  by  degenerative  changes.  Cysts 
may  be  unilocular  or  multilocular,  and  are  found  in  the  ovary  and  in  the 
breast.  In  the  ovary,  multilocular  cysts  form  large  tumours  generally 
composed  of  one  or  two  very  large  cysts,  and  numbers  of  smaller  ones. 
The  walls  are  smooth  and  shining,  the  contents  a  clear  fluid  or  a  turbid 
glairy  material ;  papillary  outgrowths  are  not  uncommonly  present  in 
their  interior.  The  cysts  of  the  breast  are  similar  in  character,  but 
smaller,  while  the  intra-cystic  growth  may  be  more  markedly  developed. 
Cysts  may  be  the  result  of  degeneration  in  tumours  or  they  may  be  due 
to  the  dilatation  of  previously  existing  cavities,  such  as  sebaceous  cysts, 
hydronephrosis,  hydroceles,  etc.,  but  these  cannot  be  classed  as  true 
tumours. 

Complex  Tumours. — These  may  be  solid  or  cystic  ;  they  are  con- 
genital, and  generally  contain  a  variety  of  tissues.  They  are  most  fre- 
quently met  with  over  the  sacrum,  forming  the  sacro-coccygeal  tumours, 
and  may  contain  bone,  connective  tissue,  muscle,  nerves,  cartilage, 
epithelium,  etc.  ;  cysts  also  are  often  present.  Another  form  of  con- 
genital complex  tumour  is  the  dermoid  cyst,  the  lining  wall  of  which  is 
composed  of  structures  resembling  skin,  containing  the  skin  glands  as 
well  as  hairs,  and  often  teeth  and  even  bone.  They  occur  in  the  ovary 
and  in  various  parts  where  epithelial  structures  may  have  been  included 
during  development,  more  particularly  in  the  neck  in  connection  with 
the  branchial  clefts  and  about  the  root  of  the  nose  or  the  angular  process 
of  the  frontal  bone. 

The  treatment  of  these  tumours  is  described  in  connection  with  that 
of  the  affections  of  the  organs  in  which  they  occur. 


DIVISION    V. 
DEFORMITIES. 

CHAPTER    XIV. 

DEFORMITIES  AFFECTING  THE   FINGERS  AND  TOES. 

IN  this  division  will  be  included  the  various  deformities  of  the  extremities 
(along  with  scoliosis)  which  are  usually  grouped  together  under  Orthopaedic 
Surgery.  Deformities  in  other  regions  will  be  discussed  in  connection 
with  the  affections  of  those  regions. 

Deformities  may  be  divided  into  two  great  groups — congenital  and 
acquired  deformities.  Of  the  former  we  shall  only  deal  with  those  that 
can  be  improved  by  treatment ;  those  for  which  nothing  surgical  can  be 
done  will  not  be  described. 

The  acquired  deformities  are  due  to  such  various  causes  and  a  number 
of  causes  are  so  often  at  work  in  any  given  case  that  it  is  not  possible 
to  group  them  according  to  their  causes.  We  shall  therefore  describe 
them  according  to  the  regions  in  which  they  occur. 

SUPERFLUOUS  DIGITS. 

The  number  of  supernumerary  digits  varies  widely  ;  in  some  cases 
ten  in  all  have  been  met  with.  The  condition  is  usually  bilateral  and 
frequently  affects  both  hands  and  feet.  In  the  foot  it  is  commonest  to 
find  a  supernumerary  toe  on  the  outer  side,  forming  an  accessory  little 
toe.  In  the  hand  the  most  usual  deformity  is  an  accessory  little  finger, 
but  an  additional  thumb  is  not  at  all  infrequently  met  with.  The  degree 
of  development  of  the  supernumerary  member  varies  within  wide  limits  ; 

267 


268 


DEFORMITIES 


sometimes  a  complete  digit  is  met  with — that  is  to  say,  there  are  three 
distinct  phalanges  (or,  in  the  case  of  the  thumb,  two)  perfectly  developed. 
It  is  very  rarely  that  reduplication  of  a  metacarpal  or  metatarsal  bone 
also  occurs  ;  but  if  it  does,  the  additional  digit  then  articulates  with  the 
carpus  or  tarsus  respectively.  The  first  phalanx  of  the  supernumerary 
digit  is  generally  attached  to  the  side  of  the  metacarpal  bone,  either  with 
or  without  a  proper  articulation.  It  is  common  to  find  no  trace  of  a 
joint,  the  union  between  the  superfluous  digit  and  the  metacarpal  bone 
being  effected  by  means  of  fibrous  tissue  ;  in  other  cases  there  is  a  well- 
formed  joint  on  the  lateral  surface  of  the  metacarpal  bone,  furnished 


FIG.  66. — DIAGRAMS  TO  ILLUSTRATE  THE  FORMS  OF  SUPERFLUOUS  DIGITS.  In  A  the  con- 
nection between  the  digit  and  the  rest  of  the  hand  is  of  skin  and  fibrous  tissue  only.  In 
B  there  is  a  distinct  articular  surface  on  the  lateral  aspect  of  the  metacarpal  bone.  In 
C  there  is  a  supernumerary  metacarpal  bone  as  well  as  the  phalanges.  D,  One  form  of 
bifid  terminal  phalanx. 

with  articular  cartilage,  ligaments,  etc.  In  other  cases,  again,  the  con- 
dition is  that  of  bifid  finger  or  toe,  and  this  is  more  often  seen  in  the 
thumb  than  in  the  other  fingers  ;  the  terminal  phalanx  is  split  and  two 
complete  phalanges  may  be  present,  each  possessing  a  separate  nail 
(see  Fig.  66,  D}.  Frequently,  however,  the  division  in  the  terminal 
phalanx  does  not  extend  through  its  whole  length,  but  only  affects  the 
tip  ;  the  base  of  the  phalanx  is  then  undivided. 

TREATMENT. — The  removal  of  the  supernumerary  digit  is  the 
only  remedy  for  this  condition.  It  is  not  usually  a  matter  of  consequence 
if  a  supernumerary  toe  be  retained,  but  additional  fingers  are  unsightly 
and  generally  ought  to  be  taken  away.  In  order  to  make  sure  of  the 
most  satisfactory  result,  operation  should  be  done  in  early  life. 

(a)  When  the  digit  is  quite  separate  from  its  neighbour  and  is  only 
connected  with  the  side  of  the  metacarpal  bone  by  fibrous  tissue  (see 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     269 

Fig.  66,  A)  the  result  of  amputation  should  be  perfect ;  it  is  only  necessary 
to  make  an  elliptical  incision  around  the  digit  where  it  springs  from  the 
metacarpal  bone,  and  then  to  remove  it  and  the  fibrous  band  connecting 
it  with  the  bone.  With  a  nicely  planned  incision  and  primary  union,  a 
level  surface  will  be  left  showing  no  trace  of  the  additional  finger. 

(b)  When  there  is  an  actual  articulation  between  the  digit  and  the 
metacarpal  bone  (see  Fig.  66,  B)  mere  removal  of  the  finger  is  not  sufficient. 
If  the  articular  surface  be  allowed  to  remain,  a  swelling  is  left  upon  the 
side  of  the  metacarpal  bone,  and  this  increases  as  time  goes  on  from 
growth  taking  place  beneath  the  articular  surface,  so  that  there  may 
be   a  very  unsightly  projection   by  the   time   adult   age   is   reached. 
Hence  it   is  necessary  to  remove  both  the  superfluous  digit  and  the 
articular  surface  upon  the  metacarpal  bone  to  which  it  is  attached. 
The    flaps   are    so    planned 
that  there  shall  be  no  excess 
of  tissue  left  when  they  are 
brought  together  ;  after  the 
finger    has   been    disarticu- 
lated    and     removed,    the 
articular     surface     on    the 
metacarpal  bone  is  exposed, 
and  enough  bone  is  gouged 
away  to  render  the  shaft  of 
the  bone  smooth  and  uni- 
form in  thickness. 

(c)  When  there  is  a  super- 
numerary   metacarpal    bone 
articulating  with  the   carpus 
(see  Fig.  66,  C),  it  must  be 
removed     along    with    the 
finger  ;  when  that  has  been 

done,  enough  bone  must  be  removed  from  the  side  of  the  carpus  to 
make  the  outline  of  the  hand  resemble  that  of  the  opposite  side.  This 
involves  opening  the  wrist  joint,  and  therefore  the  operation  is  one 
that  ought  not  to  be  undertaken  unless  the  surgeon  be  certain  of  his 
ability  to  keep  the  wound  aseptic.  The  aesthetic  results,  however,  are 
very  satisfactory,  as  the  unsightly  projection  at  the  side  of  the  wrist  can 
be  obliterated  and  little  trace  of  the  deformity  left. 

(d)  In  the  case  of  a  bifid  finger,  especially  a  bifid  terminal  phalanx  of 
the  thumb  (see  Fig.  66,  D) ,  the  result  of  treatment  is  not  so  satisfactory. 
The  two  portions  of  the  phalanx  usually  diverge  from  each  other,  so  that, 
whichever  be  removed,  the  remaining  one  is  out  of  line  with  the  rest  of 
the  limb,  and  it  is  very  difficult  to  bring  it  straight ;  that,  however,  must 
be  the  aim  of  the  operation.    In  the  first  place,  the  phalanx  which  deviates 
most  from  the  axis  of  the  finger  (usually  the  smaller  of  the  two)  should 


FIG.  67.— INCISIONS  FOR  THE  REMOVAL  OF  A  SUPER- 
NUMERARY THUMB. 


270 


DEFORMITIES 


be  amputated  by  an  elliptical  incision  over  the  corresponding  side  of  the 
digit.  The  flaps  should  be  cut  so  as  to  avoid  removing  too  much  skin. 
If  the  supernumerary  portion  be  sessile,  this  may  be  difficult  and  the 
safest  way  will  be  to  make  a  free  incision  along  one  edge  of  it  and  split 
it  open.  The  bone  can  then  be  dissected  out,  and  it  will  be  easy  to 
trim  up  the  soft  parts  so  as  to  make  flaps  which  meet  satisfactorily. 

When  the  phalanx  is  not  completely 
bifid  it  should  be  split  down  to  its  base  with 
bone  forceps  and  the  desired  half  removed. 
After  this  has  been  done,  the  lateral  liga- 
ments on  the  opposite  side  of  the  joint  will 
usually  require  division,  so  that  the  part 
of  the  phalanx  left  may  be  brought  into 
line  with  the  rest  of  the  finger.  This  should 
be  done  from  the  interior  of  the  joint,  which 
will  already  have  been  opened  in  removing 
the  other  half  of  the  phalanx.  Any  other 
structures  that  are  tense  and  resist  re- 
position must  also  be  divided. 

Immediately  after  the  operation,  a  narrow 
splint  may  be  applied  to  the  opposite  side  of 
the  finger  to  that  on  which  the  deflection 
is,  and  the  phalanx  drawn  outwards  towards 
it ;  when  the  wound  has  healed,  however, 
it  is  best  to  fix  the  digit  and  the  wrist  in  a 

silicate  bandage,  which  interferes  less  with  the  movement  of  the  rest 
of  the  hand  than  the  wooden  splint  does.  This  casing  may  be  split 
along  one  side  and  should  be  removed  at  first  once  a  week,  and  finally 
every  day,  so  that  massage  and  passive  movement  may  be  practised ; 
otherwise  the  joint  may  become  very  stiff.  About  six  weeks  after  the 
operation  the  silicate  case  may  be  replaced  by  a  metal  splint,  moulded 
to  the  wrist  and  forearm,  and  prolonged  down  along  one  side  of  the 
digit ;  the  terminal  phalanx  is  strapped  to  this  so  as  to  keep  it  in 
proper  position  (see  Fig.  68). 

WEBBED   DIGITS. 

This  condition  affects  both  toes  and  fingers,  but  in  the  former  case  it 
does  not  usually  cause  any  inconvenience,  and  no  treatment  is  necessary. 
The  presence  of  a  web  between  the  fingers,  however,  is  a  great  disadvan- 
tage ;  it  is  unsightly,  it  prevents  the  proper  separation  of  the  digits,  and 
it  thus  interferes  greatly  with  the  usefulness  of  the  hand  ;  moreover, 
fingers  so  united  do  not  develop  as  well  as  those  which  are  free.  In 
almost  all  cases,  therefore,  it  is  necessary  to  attempt  to  remedy  the 
deformity. 

The  cases  of  webbed  finger  vary  considerably,  both  as  to  the  extent 


Fie.  68. — SPLINT  FOR  THE  AFTER- 
TREATMENT  OF  BIFID  FINGER. 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES    271 

of  the  web  in  the  downward  direction  and  the  closeness  with  which  the 
fingers  are  bound  together.  In  some  cases  (Fig.  69,  A)  there  is  merely 
a  slight  extension  downwards  of  the  natural  web  between  the  fingers, 
which  may  only  reach  as  low  as  the  first  interphalangeal  joint.  This 
web  is  usually  loose  and  does  not  inconvenience  the  patient,  whose  chief 
reason  for  seeking  surgical  advice  is  rather  to  have  an  unsightly  deformity 
removed  than  to  have  the  usefulness  of  the  hand  increased.  In  others, 
again,  the  web  extends  right  down  to  the  terminal  phalanges,  and  these 
cases  may  be  divided  into  three  groups  :  (i)  those  in  which  the  web  is  quite 
broad  and  allows  considerable  play  to  the  fingers  (Fig.  69,  B)  ;  (2)  those  in 
which  the  fingers  are  bound  closely  together  by  a  narrow  web,  but  with- 
out any  actual  fusion  of  adjacent  bones  (Fig.  69,  C)  ;  and  (3)  those  in 
which  the  bones  of  the  adjacent  fingers  are  more  or  less  completely  welded 
together  (Fig.  69,  D). 


FIG.  69. — DIAGRAMS  TO  ILLUSTRATE  THE  DEGREES  OF  WEBBED  FINGERS.  A  and  B 
show  two  forms  of  the  broad  and  extensile  web  ;  in  A  it  is  a  slight  prolongation  of  the 
normal  web,  while  in  B  it  reaches  almost  to  the  finger-tips.  C  shows  the  fingers  bound 
together  throughout  their  whole  length  so  closely  that  there  is  practically  no  web  between 
them.  In  D  the  bones  of  the  adjacent  fingers  are  fused  together. 


TREATMENT.— When  the  Web  is  Broad.— Many  operations 
have  been  introduced  for  the  separation  of  webbed  fingers,  but  none 
of  them  is  altogether  satisfactory  except  for  the  cases  in  which  the 
web  is  broad  and  extensile.  The  two  chief  difficulties  in  the  operative 
treatment  are,  the  constant  tendency  to  the  re-formation  of  the  web  after 
division,  and  the  tendency  to  contraction  of  the  finger  or  fingers 
(especially  in  the  direction  of  flexion)  after  they  have  been  separated. 

If  the  web  be  simply  divided  down  the  centre,  it  will  be  found  that 
the  web  re-forms  as  the  wound  heals,  and  no  mechanical  arrangement 
seems  able  to  prevent  this.  Various  methods  have  been  employed  in  order 
to  prevent  this  re-formation  of  the  web ;  for  this  rapid  healing  at  the  cleft 
between  the  fingers  is  essential.  The  two  following  methods  are  employed 
with  this  end  in  view. 

The  Ear-ring  Perforation. — In  the  perforation  method  the  plan 
adopted  is  practically  identical  with  that  employed  in  perforating  the  ear 
for  ear-rings  (see  Fig.  70).  A  hole  is  made  through  the  base  of  the 
web  and  a  piece  of  stout  silver  wire  is  inserted  through  it,  bent  loosely 
round  one  of  the  fingers  into  a  ring,  and  kept  in  position  until  cicatrisation 


272 


DEFORMITIES 


FIG.  70. — THE  EAR-RING  PERFORATION 
OPERATION  FOR  WEBBED  FINGERS. 
Three  stages  of  the  operation  are  shown. 
On  the  left  is  the  ring  of  silver  wire  in 
situ :  in  the  centre  the  web  is  being 
divided  after  cicatrisation  of  the  perfora- 
tion, while  on  the  right  are  seen  the  redun- 
dant edges  ready  to  be  trimmed  off. 


is  complete.     This  requires  some  five  or  six  weeks,  at  the  end  of  which 

time  a  knife  is  introduced  into  the  hole  and  the  web  split  down  to  the 

free  edge.  If  possible,  the  cut  edges  on 
each  side  of  the  cleft  should  be  united  by 
sutures  so  as  to  secure  immediate  union 
and  avoid  a  granulating  wound,  which 
would  undergo  contraction.  After  this 
operation,  even  in  favourable  cases,  con- 
siderable contraction  may  still  take  place. 
The  V-shaped  Flap. — A  more  satisfac- 
tory method  is  to  turn  a  flap  into  the 
cleft  after  the  web  has  been  divided.  The 
best  way  of  doing  this  is  to  cut  a  tri- 

\  jjf  angular  flap  with  its  apex  downwards 

X  Jf  from  the  dorsal  surface  of  the  base  of  the 

jtj  web  (see  Fig.  71).  A  triangular  flap,  the 

apex  of  which  is  in  the  centre  of  the 
web  sufficiently  low  down  to  enable  the 
flap  to  be  folded  into  the  cleft  and 
stitched  to  the  skin  of  the  palm,  is 
marked  out  by  carrying  an  incision 
upwards  on  each  side  from  this  point 
to  one  a  little  to  the  side  of  the  corre- 
sponding phalanx  and  opposite  the  base 

of  the  web.     This  flap,  consisting  of  skin 

and  fat,  is  dissected  up,  and  then  the  web 

is  split  down  the  centre.     The  flap  is  now 

folded  down  between   the  fingers,  its  apex  is 

stitched  to  the  palmar  edge  of  the  cleft,  and 

its  sides  to  the  adjacent   skin  edges.     The 

result  is  that  immediate  union  takes  place 

and  no  contraction  occurs.     The  raw  surface 

on  each   finger  left  by  splitting  the  web  is 

then  trimmed,  and  the  edges  stitched  accu- 
rately together  so  as  to  obtain  union  by  first 

intention.     The  granular  fat  often  projects 

between  the  edges  of  the  skin  and  prevents 

accurate  apposition ;  when  this  is  the  case, 

it  should  be  clipped  away  before  the  sutures 

are  inserted.     If  a  small  space  be  left  near 

the  cleft   where   the  edges   will   not    come 

together,  it  is  well  to  place  a  skin-graft  over 

the  raw  surface.     This  operation  is  useful  for 

partial  and  complete  webs,  and  is  the  best  that  can  be  adopted,  provided 

that  there  is  plenty  of  room  between  the  fingers. 


FIG.  71. — THE  V-SHAPED  FLAP 
OPERATION  FOR  WEBBED  FINGERS. 
The  three  stages  of  the  operation  are 
here  shown.  In  the  centre  the  flap 
has  been  marked  out ;  on  the  right  it 
has  been  dissected  up,  while  on  the 
left  it  has  been  turned  down  and 
sutured  into  the  cleft. 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES    273 

When  the  Web  is  Narrow. — This  is  a  much  more  difficult  con- 
dition to  treat  successfully.  Under  these  circumstances  the  operation 
just  described  is  unsuitable,  for  although  healing  might  be  obtained  at 
the  cleft,  a  large  raw  surface  would  be  left  along  the  side  of  each  finger, 
which  would  contract  and  lead  to  lateral  bending  and  flexion  of  the 
fingers  if  it  were  allowed  to  heal  by  granulation ;  the  patient  would  finally 
have  the  fingers  flexed  and  bent  to  one  side,  with  a  rigid  scar  running 
along  the  flexor  aspect  of  the  finger  on  that  side.  This  contraction  may 


FIG.  72. — DIDOT'S  OPERATION  FOR  WEBBED  FINGERS.  A  and  B  in  the  upper  row 
show  the  incisions.  C  shows  the  fingers  separated.  In  the  lower  row  are  diagrammatic 
cross-sections  of  two  adjacent  fingers  before,  during,  and  after  operation. 

be  prevented  to  some  extent  by  immediate  skin-grafting  (see  p.  52),  a 
single  long  graft  being  applied  to  the  raw  surface  on  each  side,  and  the 
fingers  being  bound  together  and  left  undisturbed  for  ten  days.  The 
result  of  skin-grafting  in  these  cases,  however,  is  not  generally  satisfactory, 
as  contraction  often  occurs  in  spite  of  it.  Simple  splitting  and  skin- 
grafting  is  therefore  not  to  be  recommended. 

Didot's  Operation. — The  operation  most  commonly  adopted  for 
this  particular  form  of  the  deformity  is  that  known  as  Didot's  (see 
Fig.  72).  It  is  performed  as  follows  :  two  incisions  are  made,  one  along 
the  middle  of  the  dorsal  sui  face  of  one  finger,  and  another  along  the  middle 
of  the  palmar  surface  of  the  other,  from  a  point  opposite  the  free  end  of 


274 


DEFORMITIES 


the  web  as  far  up  as  the  knuckle.  At  each  end  of  these  two  vertical 
incisions  a  transverse  one  is  carried  across  to  the  adjacent  border  of  the 
other  finger,  and  thus  two  flaps  are  marked  out,  which  are  carefully 
dissected  up  to  the  interval  between  the  bones.  When  this  point  is  reached, 
the  soft  structures  are  split  between  the  bones,  and  there  is  then  a  flap 
attached  to  each  of  the  separated  fingers,  formed  by  the  skin  of  the  front 
or  back  of  the  corresponding  fingers  respectively  ;  the  base  of  these  flaps 
is  on  the  palmar  surface  of  one  finger,  and  on  the  dorsal  of  the  other.  Each 
flap  is  then  wrapped  round  the  side  of  the  finger  to  which  it  belongs  and 
is  stitched  in  place,  the  one  along  the  back,  the  other  along  the  front. 

The  flaps,  however,  are  seldom  broad  enough 
to  meet  the  line  of  incision  in  front  or  behind, 
and  generally  an  interval,  sometimes  a  con- 
siderable one,  is  left  between  the  edge  of  the 
flap  and  the  edge  of  the  skin  to  which  it  should 
be  stitched.  In  these  intervals  the  fat  pro- 
trudes, and  ultimately  a  narrow  line  of 
granulation-tissue  forms  ;  this  contracts,  and 
may  give  rise  to  considerable  deformity.  In 
order  to  obtain  rapid  healing,  Thiersch's  skin- 
grafts  (see  p.  52)  should  be  laid  on  this  narrow 
line  at  the  time  of  the  operation ;  but  in  this 
operation,  as  in  the  previous  one,  the  grafts 
do  not  prevent  the  occurrence  of  a  certain 
amount  of  contraction.  The  final  outcome 
of  the  operation  is  generally  that  the  result  is 
good  in  one  finger,  while  in  the  other  it  is 
poor.  The  one  that  has  the  palmar  flap  is 
usually  satisfactory,  as  the  narrow  scar  which 
forms  along  the  dorsum  does  not  interfere 
with  movement ;  the  patient  can  always  flex 

the  finger,  and  thus  undue  contraction  is  prevented.  On  the  other  hand, 
the  finger  which  has  the  dorsal  flap,  and  in  which  the  cicatrix  lies  along 
the  palmar  surface,  generally  becomes  contracted,  the  narrow  scar  causing 
flexion  of  the  finger,  and  consequently  an  imperfect  result.  This  tendency 
of  the  finger  which  has  the  dorsal  flap  to  become  contracted  must  be  borne 
in  mind,  and  skin-grafting  should  always  be  employed  over  any  portion 
that  is  left  raw,  and,  besides  this,  a  splint  must  be  worn  for  a  long  time, 
so  as  to  keep  the  finger  extended.  The  splint  (see  Fig.  73)  should  be 
applied  to  the  dorsal  surface,  taking  purchase  from  the  lower  part  of  the 
forearm  and  back  of  the  hand ;  opposite  the  knuckles  a  prolongation 
extends  along  the  back  of  the  finger,  and  to  this  the  latter  is  strapped. 
The  splint  should  be  worn  day  and  night,  being  only  left  off  at  intervals 
to  permit  of  passive  movement  ;  at  the  end  of  two  months  it  may  be 
left  off  during  the  day,  but  should  be  worn  at  night  for  at  least  six  months, 


FIG.  73. — SPLINT  FOR  USE  AFTER 
DIDOT'S  OPERATION.  The  splint  is 
made  of  well-padded  metal,  and  the 
finger  prolongation  can  be  bent  back 
to  any  desired  extent  so  as  to 
counteract  all  tendency  to  flexion. 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     275 

and  generally  for  a  year.  There  is  a  strong  tendency  to  the  formation  of 
a  cicatricial  ridge  along  the  palmar  surface  of  one  finger,  and  consequent 
contraction,  in  spite  of  the  splint. 

When  several  fingers  are  united,  it  is  well  to  separate  only  two  at  a 
time,  and  to  allow  some  weeks,  or  even  months,  to  elapse  before  proceed- 
ing to  separate  a  second  pair.  There  is  a  distinct  advantage  in  doing 
the  operation  at  an  early  age,  because  the  webbing  of  the  fingers  un- 
doubtedly interferes  with  their  growth ;  a  finger  that  has  been  freed 
grows  faster  than  one  that  is  still  webbed.  At  the  same  time,  the  hand 
in  infants  is  so  small  and  so  difficult  to  fix  that  it  will  generally  be 
found  best  to  wait  until  the  child  is  a  year  or  two  old  and  the 
fingers  have  attained  a  length  and  size  more  suited  for  the  application 
of  splints. 

When  the  Bones  are  United. — When  there  is  bony  union 
between  the  adjacent  phalanges,  treatment  is  much  more  difficult 
and  sometimes  it  is  doubtful  whether  it  is  advisable  to  interfere 
with  them .  at  all.  When  the  deformity  is  marked,  and  the  finger 
is  not  so  useful  as  it  might  be  were  the  deformity  overcome,  an 
attempt  may  be  made  to  remedy  it.  The  only  proceeding  that  offers 
any  prospect  of  success,  however,  is  to  remove  a  portion  of  the  welded 
bones  so  as  to  obtain  one  good  finger  instead  of  two  bad  ones ;  if 
any  attempt  were  made  to  separate  the  fingers,  there  would  not  be 
sufficient  covering  for  the  two  raw  surfaces.  When,  however,  one  bone 
has  been  dissected  out,  the  skin  covering  the  portion  of  the  finger 
taken  away  will  be  sufficient  to  cover  the  raw  surface  left,  and  there 
may  be  less  deformity  and  greater  mobility.  The  precise  steps  to  be 
adopted  in  operating  must,  however,  depend  on  the  condition  present, 
and  cannot  be  described  here. 


HAMMER  TOE. 

By  the  term  '  hammer  toe '  is  understood  a  deformity  of  which  the 
essential  element  is  flexion  of  the  first  interphalangeal  joint  of  the 
toe;  there  is  also  generally  a  secondary  hyper-extension  of  the  first 
phalanx  on  the  metacarpal  bone.  The  terminal  phalanx  usually  retains 
its  normal  position,  but  in  bad  cases  it  may  be  in  the  same  straight  line 
with  the  second,  so  that  the  last  two  phalanges  have  their  long  axes 
directed  vertically  downwards,  and  the  tip  of  the  toe  comes  into  contact 
with  the  ground.  The  terminal  joint  may  be  hyper-extended,  however, 
the  result  being  that  the  toe  resembles  the  letter  Z  (see  Fig.  74).  The 
deformity  usually  affects  the  second  toe,  but  it  may  affect  others. 

Hammer  toe  may  be  congenital,  and  is  then  often  hereditary;  in 
these  cases  it  is  not  usually  marked  until  the  patient  begins  to  walk.  It 
may  also  be  acquired,  and  the  chief  cause  is  the  presence  of  the  condition 
known  as  hallux  valgus ;  the  great  toe  is  adducted,  overrides  and 

T  2 


276 

causes  flexion  of  the  second  phalanx  of  the  second  toe,  and  the  typical 
deformity  just  mentioned. 

The  condition  is  sometimes  very  troublesome  on  account  of  the  de- 
velopment of  corns  upon  the  points  exposed  to  pressure  ;    when  there 


FIG.  74. — HAMMER  TOE.  The  figure  illustrates  the  two  varieties  of  the  affection. 
On  the  left-hand  side  is  the  Z-shaped  deformity,  in  which  there  is,  besides  hyper- 
extension  at  the  metatarso-phalangeal  joint,  flexion  at  the  first  and  hyper-extension  at 
the  second  interphalangeal  articulation.  In  the  other  figure  the  deformity  is  similar, 
except  that  the  terminal  phalanx,  instead  of  being  hyper-extended  upon  the  second,  is 
in  the  same  straight  line  with  it. 

are  no  corns  it  gives  rise  to  no  trouble  whatever.  There  is  generally  a 
large  and  tender  corn  over  the  first  interphalangeal  joint  where  it  rubs 
against  the  boot,  and  also  on  the  free  end  of  the  toe,  especially  when  the 
terminal  phalanx  looks  straight  downwards ;  the  corn  is  then  often 
situated  just  behind  the  free  edge  of  the  nail,  which  is  somewhat  recurved, 
and  it  causes  intense  pain  when  the  patient  walks.  Corns  also  form 
on  the  inner  aspect  of  the  toe  where  the  great  toe  comes  into  contact 
with  it. 

PATHOLOGICAL  CHANGES.— The  ligaments  of  the  first 
interphalangeal  joint,  in  particular  the  lateral  and  the  plantar  or  glenoid 
ligaments,  are  markedly  shortened  when  the  deformity  is  once  established. 


FIG.  75. — DIAGRAM  TO  SHOW  HOW  FORCIBLE  STRAIGHTENING  OF  A  HAMMER  TOE 
MAY  RESULT  IN  DISLOCATION.  The  lateral  ligaments,  which  are  shown  in  the  figure, 
are  attached  on  each  bone  at  a  point  somewhat  below  the  centre  of  the  lateral  aspect. 
Any  attempt  at  forcible  straightening  while  the  ligaments  are  intact  must  therefore 
either  fail  or  result  in  dislocation  of  the  base  of  the  second  phalanx  beneath  the 
head  of  the  first,  as  shown  in  the  right-hand  figure. 

This  is  accompanied  by  secondary  contraction  of  the  flexors  of  the  toes 
(which,  however,  does  not  occur  until  a  late  period)  and  by  alterations 
in  the  articular  surfaces.  In  bad  cases  the  second  phalanx  is  actually 
drawn  up  under  the  first,  leaving  the  articular  surface  of  the  latter 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES      277 

entirely  uncovered.  Hence,  attempts  made  to  straighten  the  joint 
forcibly,  even  after  tenotomy  of  the  flexor  tendons,  result  in  a  disloca- 
tion of  the  second  phalanx  beneath  the  first  (see  Fig.  75).  The  articular 
cartilage  over  the  head  of  the  first  phalanx  rapidly  becomes  converted 
into  fibrous  tissue,  so  that  an  imperfect  joint  must  result,  even  if  the 
joint  surfaces  be  restored  to  their  relative  position. 

TREATMENT.—  The  treatment  of  this  deformity  is  somewhat 
troublesome  ;  it  may  be  carried  out  in  three  ways  :  (i)  by  means  of 
mechanical  appliances  designed  to  prevent  or  overcome  the  flexion  of 
the  second  phalanx  ;  in  acquired  cases  this  should  be  combined  with 
treatment  directed  to  the  cure  of  the  co-existing  hallux  valgus  and  also 
with  division  of  the  contracted  ligaments  or  other  structures  around 
the  joint  ;  (2)  by  removal  of  the  head  of  the  first  phalanx  so  as  to  allow 
the  phalanges  to  be  brought  straight  ;  and  (3)  by  amputation. 

Appliances.  —  In  the  less  advanced  cases  it  is  best  to  commence 
by  dividing  the  lateral  and  glenoid  liga- 
ments of  the  first  interphalangeal  joint  and 
(in  the  rarer  cases  calling  for  it)  the  flexor 
tendon  before  employing  mechanical  ap- 
pliances ;  a  tenotome  with  a  very  small 
cutting  blade  should  be  used  for  the  pur- 
pose. The  line  of  the  joint  is  defined 
by  the  finger-nail,  and  the  point  of  the 
knife  made  to  penetrate  the  skin  at  right-  FIG.  76.—  T-SHAPED  SPLINT  FOR 
angles  to  the  long  axis  of  the  toe  at  the 


junction  of  its  dorsal  and  lateral  aspects,     Joint  ^y  be  ob^ed  if  necessary  by 

,.  i_jj-  ij  •  i        •    •  inserting  a  pad  of  lint  or  wool  between 

and  IS  pushed  directly  dOWn  into  the  ]Oint,        the  tip  of  the  toe  and  the  splint. 

the   lateral  ligament   to  be  divided  being 

rendered  tense  by  lateral  pressure  on  the  point  of  the  toe.  Slight  move- 
ment of  the  knife  generally  divides  the  ligament  immediately,  when  the 
process  is  repeated  on  the  opposite  side.  The  toe  is  then  forcibly 
straightened  and  is  secured  to  an  apparatus  designed  to  prevent  recur- 
rence of  the  flexion.  A  convenient  form  is  a  T-shaped  splint  (see 
Fig.  76),  the  horizontal  limb  passing  transversely  beneath  the  sole 
about  the  level  of  the  tarso-metatarsal  articulations,  and  being 
secured  there  by  means  of  a  strap  or  band,  while  the  vertical  part 
extends  underneath  the  toe  as  far  as  its  tip  ;  the  splint  should  be  well 
padded,  and  the  toe  strapped  down  to  it.  The  treatment  of  the  co- 
existing hallux  valgus  (see  p.  281)  should  never  be  neglected,  as  it  is  most 
important  to  prevent  the  pressure  of  the  first  toe  on  the  second.  No 
permanent  good  is  likely  to  accrue  if  the  hammer  toe  be  straightened 
and  the  hallux  valgus  left  untreated. 

This  procedure  is  only  of  use  in  the  milder  forms  ;  in  the  more  severe 
ones,  particularly  those  that  are  congenital  in  origin,  the  toe  will  not 
come  straight  even  after  division  of  the  ligaments  and  tendons,  for  the 


278 


DEFORMITIES 


skin  and  the  other  soft  structures  are  permanently  shortened,  and 
forcible  attempts  to  straighten  the  joint  result  in  dislocating  the  base 
of  the  second  phalanx  below  the  head  of  the  first.  In  severe  cases  also 
the  articular  surfaces  are  so  much  altered  that  an  imperfect  result  would 
be  obtained  even  if  they  were  brought  properly  into  contact. 

When  there  is  flexion  of  all  the  toes,  as  may  be  the  case  in  pes  cavus, 
a  special  splint  with  bands  passing  over  the  dorsal  surface  of  each  toe 
will  be  required  (see  Fig.  77).  Later  on,  when  the  tendency  to  flexion 
has  been  greatly  reduced,  an  efficient  splint  may  be  made  by  attaching 
a  stout  glove-finger  of  suitable  size  to  a  piece  of  whalebone  or  flexible 
steel  covered  with  chamois  leather;  this  lies  on  the  dorsum  of  the  foot 


FIG.  77. — SPLINT  FOR  ALL  THE 
TOES.  This  is  used  when  there  is 
contraction  of  several  toes. 


FIG.  78. — SPLINT  FOR  USE  IN  AFTER- 
TREATMENT  OF  HAMMER  TOE.  This  is  one 
that  can  be  easily  improvised,  and  is  suitable 
for  use  where  it  is  merely  desired  to  prevent 
the  recurrence  of  flexion.  It  is  made  of  whale- 
bone or  light  flexible  steel,  which  can  be  bent 
to  fit  the  outline  of  the  foot.  If  preferred,  it 
can  be  made  to  lie  along  the  sole  of  the  foot. 


beneath  the  stocking,  and  is  fastened  by  a  broad  tape  round  the  instep. 
The  toe  goes  into  the  glove-finger  (see  Fig.  78). 

Since  some  form  of  splint  must  be  worn  for  a  long  time  and  may  be 
required  permanently,  it  becomes  a  question  whether  it  is  worth  the 
patient's  while  to  submit  to  this  method  of  treatment.  We  are  of  opinion 
that  in  all  except  the  slightest  cases  it  is  best  to  practise  some  form  of 
operation  which  obviates  the  necessity  of  using  a  splint,  and  which  gives 
satisfactory  results  without  laying  the  patient  up  for  any  length  of  time. 

Excision  of  the  Head  of  the  First  Phalanx.— The  operative 
procedures  which  may  be  adopted  are  removal  of  the  head  of  the  first 
phalanx,  excision  of  the  joint,  or  amputation.  The  third  method  is  not  to 
be  recommended ;  removal  of  the  toe,  in  acquired  cases,  simply  favours 
the  increase  of  the  hallux  valgus;  an  exception  may  be  made  in  the 
case  of  working  men,  who  wish  to  get  to  work  as  quickly  as  possible, 
and  who  therefore  insist  on  amputation.  We  strongly  advise  the  removal 
of  the  head  of  the  first  phalanx  in  all  but  the  slightest  cases.  If  enough 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES    279 

bone  be  removed,  the  toe  can  be  straightened  without  any  tension,  and 
there  is  no  need  to  divide  ligaments  or  tendons  in  the  first  instance. 
This  gives  the  patient  a  movable  joint  which  has  little  tendency  to  become 
flexed  again  ;  the  result  is  much  better  than  that  of  excision  of  both  the 
articular  surfaces. 

The  operation  is  done  as  follows.  An  incision  is  made  along  the 
dorsal  surface  of  the  toe  parallel  to  and  a  little  to  one  side  of  the  extensor 
tendon  ;  it  should  commence  an  inch  above  the  first  interphalangeal 
joint  and  run  down  well  beyond  it.  The  incision  is  carried  directly 
down  to  the  bone,  and  the  soft  structures  are  separated  from  the  end  of 
the  first  phalanx  by  a  periosteum  detacher  and  a  few  strokes  of  the 
knife.  The  lateral  ligaments  are  then  divided  and  the  head  of  the  bone 
is  made  to  project  into  the  wound  and  is  nipped  off  by  cutting  pliers. 
The  bone  is  generally  divided  about  a  quarter  of  an  inch  above  the 
articular  surface,  but  enough  must  be  removed  to  allow  the  toe  to  be 
brought  straight  without  any  tension.  After  the  bleeding  has  been 
arrested,  the  corn  over  the  first  interphalangeal  joint  is  excised,  the 
wound  united  by  fine  sutures,  and  a  gauze  dressing  applied.  The  plantar 
splint  referred  to  above  (see  p.  277)  is  then  applied,  with  an  extra 
amount  of  padding  beneath  the  tip  of  the  toe,  to  ensure  the  latter  being 
kept  straight  when  the  bandage  is  applied.  When  hallux  valgus  is 
present,  suitable  treatment  for  that  condition  (see  p.  281)  must  be  adopted 
simultaneously.  When  the  wound  has  healed,  the  toe  and  the  front 
part  of  the  foot  should  be  put  up  in  a  silicate  bandage,  and  the  patient 
allowed  to  walk.  The  bandage  can  be  dispensed  with  in  about  seven 
weeks  and  the  patient  regarded  as  well. 

After-treatment. — Special  attention  must  be  paid  to  the  boots, 
which  should  not  be  too  short,  as  otherwise  the  end  of  the  toe  will  be 
pressed  upon  and  flexion  will  recur.  As  there  will  often  be  hallux  valgus 
co-existing,  the  remarks  made  with  reference  to  boots  for  hallux  valgus 
(see  p.  281)  apply  here  also.  The  socks  should  be  furnished  with  a 
separate  compartment  for  the  great  toe. 


HALLUX  VALGUS  AND  BUNION. 

By  the  term  Hallux  Valgus  is  understood  a  condition  in  which  there 
is  adduction  of  the  great  toe.  As  a  consequence  of  this  adduction,  the 
inner  side  of  the  head  of  the  first  metatarsal  bone  becomes  unduly  exposed 
and  consequently  is  subjected  to  direct  pressure  against  the  boot ;  in- 
flammation therefore  takes  place  in  the  exposed  bone  and  the  periosteum 
over  it,  and  considerable  thickening  of  these  structures  occurs.  A  bursa 
is  subsequently  developed  in  the  subcutaneous  tissues  over  the  enlarged 
bone,  a  condition  commonly  known  as  a  bunion  ;  by  an  inflamed  bunion 
is  meant  one  in  which  the  bursa  has  become  inflamed.  The  inflammatory 


280 


DEFORMITIES 


attacks  may  pass  off,  leaving  additional  thickening  of  the  surrounding 
structures,  or  they  may  go  on  to  suppuration,  which  may  be  followed 
by  extensive  cellulitis  of  the  foot,  perforation  of  the  metatarso-phalangeal 
joint  of  the  great  toe,  septic  arthritis,  necrosis,  etc.  Moreover,  as  time 
goes  on,  these  joints  frequently  undergo  the  changes  characteristic  of 
osteo-arthritis. 

In  hallux  valgus  the  great  toe  may  be  deflected  so  as  to  lie  under  or 
over  the  second ;  in  the  latter  case  (which  is  the  usual  one)  the  toe  is 
also  rotated  so  that  its  upper  surface  looks  somewhat  inwards,  and  its 


FIG.  79. — DIAGRAM  ILLUSTRATING  THE  PRINCIPLES  TO  BE  OBSERVED  IN  MAKING 
BOOTS.  C  shows  the  deflection  of  the  great  toe  and  the  cramped  position  of  the 
others  entailed  by  wearing  the  ordinary  pointed-toed  boots  ;  it  will  be  seen  that  the 
point  of  the  boot  is  opposite  to  the  middle  line  of  the  sole.  B  shows  the  outline  of  the  sole 
of  a  boot  constructed  on  sound  anatomical  principles.  The  inner  border  of  the  front  part 
of  the  sole  is  nearly  parallel  to  the  long  axis  of  the  foot,  the  boot  comes  to  a  point  opposite 
the  great  toe,  and  is  sloped  away  from  that  point  to  the  outer  border  in  accordance 
with  the  length  of  the  other  toes,  which  are  thus  not  cramped  at  all.  A ,  a  very  usual 
form  of  so-called  anatomical  boot  which,  while  it  is  free  from  the  most  flagrant  faults 
of  the  usual  pointed-toed  variety,  is  not  so  good  as  B.  The  inner  border  of  the  sole  is 
not  quite  straight,  and  so  tends  to  deflect  the  great  toe  somewhat,  while  the  squareness 
of  the  end  of  the  boot  both  leaves  a  lot  of  unnecessary  space  between  it  and  the  toes 
and  detracts  considerably  from  the  appearance  of  the  foot.  (After  Meyer.) 

inner  border  is  directed  towards  the  sole.  Thus  there  is  adduction  of 
the  toe  combined  with  rotation,  and  it  is  important  to  bear  this  compound 
deformity  in  mind  when  attempting  to  remedy  the  condition. 

The  affection  is  essentially  produced  by  ill-fitting  boots,  those  in 
which  the  toe  of  the  boot  comes  to  a  sharp  point  opposite  the  middle 
line  of  the  foot  being  the  chief  offenders.  A  boot  pointed  in  this  way 
crowds  the  toes  together,  and  if  it  must  be  brought  to  a  point,  the 
latter  should  be  towards  the  inner  side  of  the  foot  so  as  not  to  deflect 
the  great  toe  from  its  normal  line  (see  Fig.  80). 

Bunion  is  especially  marked  in  those  who  suffer  from  gout  or  rheu- 
matoid arthritis  ;  it  is  probable  that  one  of  these  conditions  is  necessary 
for  the  full  development  of  the  trouble. 

Cases  of  hallux  valgus  may  come  under  observation  :    (i)  at  an  early 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES    281 


stage,  when  the  divergence  of  the  toe  and  the  enlargement  of  the  end  of 
the  bone  are  comparatively  slight ;    (2)  when  the  condition  is  well  de- 
veloped, with   considerable  en- 
largement of  the  bone  and  the 
formation   of  a  bursa  over  it ; 
and  (3)  when  the  bursa  has  sup- 
purated and  a  sinus  is  left. 

TREATMENT.  —  In  the 
early  stage  much  may  be  done 
to  render  the  patient  comfort- 
able and  to  prevent  further 
development  of  the  deformity 
by  the  use  of  properly  con- 
structed boots  combined  with 
some  mechanical  arrangement 
designed  to  counteract  the  ad- 
duction of  the  great  toe.  The 
boots  must  be  long  enough, 
not  too  narrow,  and  the  inner 
border  of  the  sole,  as  far  as  the 
extremity  of  the  great  toe,  must 
be  almost  straight.  The  most 
suitable  boots,  on  the  whole, 

are    those    in     which     the    inner     BOUND   ITS   OUTLINE.-^  h  a  normal  foot.      B,  a  mild 

degree  of  hallux  valgus.    The  outline  in  A  with  the  corners 
border    IS     Straight     and     passes     rounded  off,  represents  the  proper  outline  for  a  boot.    B 

11      i  J       ±1 fj-U        similarly  treated  illustrates  the  faulty  shape  of  boots  made 

Well      beyond      tne     tip    Ol      tne     with  the  point  in  the  centre.     (Modified  from  Whitman.) 

great   toe,    and  of    which   the 

outer  border  is  rounded  to  correspond  to  the  curve  of  the  other  toes  (see 
Fig.  79).  They  cannot  be  said  to  be  comely,  but  nevertheless  they  must 
be  worn  in  these  cases. 

In  addition,  means  must  be  employed  to  press  the  toe  into  position 
and  to  overcome  the  adduction.  In  quite  early  cases  a  pad  of  lint 
may  be  worn  between  the  first  and  second  toes,  but  it  is  apt  to  press 
injuriously  on  the  other  toes,  and  does  not  always  attain  the  desired 
end.  A  better  plan  is  to  have  the  socks  made  with  a  separate  com- 
partment for  the  great  toe  (the  so-called  'digitated  socks'),  to  see  that 
a  suitable  boot  is  worn,  and  to  have  the  toe  frequently  manipulated 
so  as  to  bring  it  into  a  straight  line  with  the  inner  border  of  the  foot.  In 
most  cases,  however,  it  is  advisable,  for  a  time  at  least,  to  employ  some 
form  of  apparatus  to  keep  the  toe  in  its  proper  position  ;  a  common  one 
is  what  is  known  as  a  '  toe-post,'  made  by  fastening  a  vertical  piece  of 
stout  leather  to  the  sole  of  the  boot  in  the  interval  between  the  great 
and  the  second  toes  (Fig.  81).  The  great  toe  is  first  brought  straight  by 
introducing  a  small  roll  of  flannel  between  it  and  the  second  toe.  The 
boot  is  then  put  on  and  the  great  toe  slips  into  its  proper  position,  the 


282 


DEFORMITIES 


narrow  flannel  roll  between  the  two  toes  being  removed  by  pulling  upon 
a  string  fastened  to  one  end  ;  the  flannel  uncoils  and  is  withdrawn.  A 
digitated  sock  must  be  worn  if  a  toe-post  is  used.  The  plan  answers 
well  for  the  slighter  cases,  but  when  the  deflection  is  great  and  the  trouble 
is  of  long  standing,  considerable  friction  is  caused  by  the  pressure  of  the 
great  toe  against  the  post,  and  pain  and  sometimes  ulceration  results,  so 
that  the  patient  is  unable  to  continue  it.  Under  these  circumstances  a 


FIG.  81. — DIAGRAM  TO   ILLUS- 
TRATE     THE     EMPLOYMENT    OF    A 

'  TOE-POST."  The  '  toe-post '  is 
seen  in  the  cleft  between  the 
great  toe  and  the  second.  It  is 
made  of  stout  leather  or  wood, 
and  is  fixed  to  the  sole  of  the  boot, 
which  should  be  of  the  shape 
shown  in  the  figure.  The  great 
toe  is  thus  confined  in  a  com- 
partment from  which  it  cannot 
escape,  and  no  lateral  deflection  is 
permitted. 


FIG.  82. — A  METHOD  OF  IMPROVISING  A  TOE-POST. 
A  piece  of  paper  is  cut  to  the  shape  shown  in 
A  corresponding  to  the  outline  of  the  anterior  part 
of  the  foot.  This  is  divided  into  two  along  the  line  ab. 
These  pieces  are  laid  on  a  second  piece  of  paper  so  that 
the  distance  between  them  is  equal  to  twice  the  depth 
of  the  foot,  measured  between  the  great  and  second  toe. 
The  two  lines  cd  and  ef  are  now  drawn,  and  a  paper 
pattern  made  as  shown  in  B.  This  is  cut  out  in  block 
tin  which  is  folded  along  lines  corresponding  to  the 
dotted  lines  in  B,  so  as  to  produce  the  appearance  shown 
in  C.  This  is  put  into  the  boot  and  forms  a  toe-post. 


special  form  of  splint  must  be  employed.  A  great  variety  of  these  have 
been  introduced  ;  a  fairly  satisfactory  one  is  here  figured  (see  Fig.  83)  ; 
it  is  applicable  to  cases  of  medium  severity  in  which  there  is  no  marked 
rigidity.  It  consists  of  a  metal  spring  running  along  the  inner  border 
of  the  foot  and  curving  outwards  beneath  the  ball  of  the  great  toe.  The 
spring  runs  nearly  to  the  tip  of  the  great  toe,  and  to  its  extremity  is 
attached  a  band  which  passes  around  the  point  of  the  toe,  the  other  ex- 
tremity of  the  apparatus  being  fastened  to  the  ankle  by  an  elastic  band. 
Opposite  the  arch  of  the  instep  the  spring  articulates,  by  means  of  a 
movable  joint,  with  a  small  vertical  plate,  which  takes  purchase  from 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     283 

the  instep  and  acts  as  a  fulcrum.  An  elastic  band  runs  from  the  posterior 
end  of  the  splint  over  the  outer  side  of  the  foot,  around  the  ankle,  and 
down  over  the  inner  side,  where  it  is  fastened  to  a  hook  on  the  vertical 
piece  or  fulcrum.  The  effect  of  this  is  to  draw  the  posterior  end  of  the 
splint  outwards  towards  the  heel,  whereby  the  front  portion,  and  with  it 
the  great  toe,  is  carried  inwards,  and  the  faulty  position  rectified.  The 
apparatus  will  go  inside  a  boot  of  fair  size,  and  most  patients  can  wear  it 
and  walk  without  marked  inconvenience.  Any  apparatus  for  the  correc- 
tion of  this  deformity  must 
be  worn  by  night  as  well  as  by 
day,  for  if  it  be  discarded  at 
night,  the  toe  tends  to  assume 
the  faulty  position  again,  and 
the  cure  is  retarded.  Should 
there  be  any  tenderness  of  the 
joint  or  inflammation  of  the 
bursa  over  it  in  these  milder 
cases,  the  application  of  lead 
or  lead  and  opium  lotion, 
with  the  foot  in  the  elevated 
position,  usually  reduces  it 
rapidly. 

When  the  deformity  is  more  A  B 

SPVPP6    and  the  natipnt  <;iiffprc  FIG.  83.— BUNION  SPRING.    The  spring  is  applied  to  the 

>evere,  anc  >rs     foot  as  shown  in  A  and  the  g^  toe  ^cmed  to  it.  -n^ 

fulcrum  of  the  lever  a  rests  immediately  behind  the 
enlarged  head  of  the  metatarsal.  The  band  at  the  pos- 
terior end  of  the  spring  is  then  carried  outwards  across  the 
sole  at  right  angles,  across  the  front  of  the  instep,  round 
behind  the  ankle  and  downwards  again  across  the  front  of 
the  instep  to  the  inner  border  of  the  foot,  where  it  is 
attached  to  the  fulcrum  a  ;  this  is  shown  in  B.  Sufficient 
traction  must  be  exerted  on  the  band  to  pull  the  toe  into 
position ;  if  this  cause  pain,  as  much  traction  must  be 
employed  as  can  be  borne  with  comfort,  and  this  can  be 
gradually  increased.  The  boots  in  which  these  springs  are 
worn  should  have  specially  stout  soles  so  as  to  avoid  all  risk 
of  breakage.  (Krohne  and  Sesemann.) 


considerable  pain,  it  is  best  to 
adopt  operative   measures  at 
once,  for  apparatus  is  not  likely 
to  do  much  good  and  only  acts 
as  an   additional  impediment 
to  locomotion  ;  the  permanent 
enlargement  of  the  bone,  which 
is  the  chief  cause  of  the  trouble, 
cannot  be  diminished  by  any- 
thing short  of  operation.     In  addition  to  this  also,  the  bursa  over  the 
joint  will  probably  have  undergone  a  series  of  attacks  of  inflammation 
and  its  walls  will  be  permanently  thickened,  so  that  palliative  measures 
are  not  likely  to  give  more  than  temporary  relief. 

Of  the  operative  procedures  employed  for  the  cure  of  hallux  valgus 
we  prefer  the  following.  After  thorough  disinfection  of  the  part,  an 
incision  is  made  along  the  inner  border  of  the  dorsum  of  the  toe,  from 
just  beyond  the  articular  surface  of  the  head  of  the  metatarsal  bone  back- 
wards to  half  an  inch  behind  the  point  at  which  the  enlargement  of  the 
bone  ceases.  The  incision  should  be  convex  upwards,  but  its  extremities 
should  not  be  carried  too  far  down  towards  the  plantar  surface  for  fear 
of  subsequent  pain  in  the  scar  (see  Fig.  84).  A  flap  is  turned  down  so 


284 


DEFORMITIES 


as  to  expose  the  whole  of  the  enlarged  end  of  the  metatarsal,  and  the 
bursa  is  dissected  out ;  the  periosteum  should  not  be  taken  tip  with  the 
flap.  The  thickened  portion  of  the  bone  is  removed  by  means  of  a  chisel 
and  hammer,  the  line  of  the  incision  being  from  behind  forwards,  and 
parallel  to  the  long  axis  of  the  shaft  of  the  metatarsal.  The  whole  of 
the  enlarged  inner  surface  of  the  head  of  the  metatarsal  is  removed, 
and  with  it  generally  a  small  portion  of  the  articular  surface.  The 
margins  of  the  cut  bone  surface  are  rounded  off  with  a  chisel  or  a  gouge 
so  as  to  leave  them  absolutely  smooth  and  without  any  sharp  edge ; 
failure  to  adopt  this  precaution  may  lead  to  considerable  pain  afterwards, 

and  possibly  also  recurrence  of  the  trouble. 
The  internal  lateral  ligament  is  necessarily 
detached  from  its  insertion  into  the  metatarsal 
bone.  After  removal  of  the  bone,  it  is  well  to 
introduce  a  tenotomy  knife  into  the  joint  and 
to  divide  the  external  lateral  ligament  and 
any  other  resistant  structure,  so  as  to  remedy 
the  adduction  properly.  In  very  bad  cases  it 
may  be  necessary  to  divide  the  long  extensor 
tendon,  but  in  the  majority  of  cases  this  is 
not  called  for. 

After  the  ligaments  have  been  divided, 
the  toe  is  brought  forcibly  inwards,  and  the 
deformity  somewhat  over-corrected — that  is 
to  say,  the  great  toe  is  brought  into  a  posi- 
tion of  slight  abduction.i  The  rotation  of 
the  toe  upon  the  metatarsal  bone,  to  which 
reference  has  already  been  made  (see  p.  280), 
should  also  be  carefully  corrected  ;  it  is  gene- 
rally necessary  to  divide  the  outer  part  of  the 
dorsal  ligament  in  order  to  do  this.  When 
the  toe  has  been  brought  into  the  desired  position,  an  attempt  should 
be  made  to  shorten  the  internal  lateral  ligament  so  that  it  may  form  an 
obstacle  to  recurrence  of  the  deformity.  It  is  not  easy  to  do  this  accur- 
ately ;  the  best  plan  is  to  pass  catgut  sutures  through  the  remains  of  the 
ligament,  and  fasten  it  to  the  periosteum  behind  the  cut  surface  of  the 
bone.  The  wound  should  be  stitched  up  without  a  drainage-tube. 

A  straight  splint  should  be  applied  along  the  inner  border  of  the  foot 
from  the  heel  to  beyond  the  toes ;  it  should  be  padded  especially  thickly 
immediately  behind  the  area  of  operation.  When  the  posterior  part  of  the 
splint  has  been  fastened  to  the  heel  and  the  instep,  a  considerable  lateral 
deflection  of  the  toe  can  be  obtained  by  drawing  it  towards  the  extremity 
of  the  splint  by  a  separate  bandage.  The  deformity  will  then  be  over- 

1  The  terms  '  adduction  '  and  '  abduction '  are  used  in  relation  to  the  middle  line 
of  the  foot  and  not  of  the  body. 


FIG.  84. — OPERATION  FOR  HAL- 
LUX  VALGUS,  SHOWING  THE  IN- 
CISION THROUGH  THE  SKIN. 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     285 

corrected,  the  toe  being  in  a  position  of  slight  abduction  and  fully  ex- 
tended. After  ten  days  the  dressings  are  removed,  the  stitches  taken  out, 
and  the  toe  carefully  moved  by  the  surgeon  himself,  who  takes  care  to 
keep  it  in  proper  position.  Then  the  toe  is  held  in  a  position  of  slight 
abduction  and  extension  with  the  rotation  corrected,  and  a  narrow  boric 
lint  bandage  is  wound  around  it  and 
carried  up  over  the  foot  and  instep,  and 
bandages  soaked  in  a  solution  of  silicate 
of  potash  are  applied  outside  this.  It  is 
well  to  re-apply  the  wooden  splint  for 
two  or  three  days  until  the  silicate  bandage 
has  set  firmly,  when  the  patient  may  be 
allowed  to  walk  with  the  foot  in  a  gout- 
shoe. 

The  bandage  should  be  kept  on  for  six 
weeks,  when  the  toe  should  retain  its 
position  fairly  well.  Passive  movements 
should  be  carried  out  for  two  or  three 
weeks  after  this  so  as  to  get  rid  of  any 
adhesions  that  may  have  formed  during 
healing ;  these  rarely  give  rise  to  trouble, 
however.  The  patient  should  wear  a 
sock  with  a  separate  compartment  for 
the  great  toe,  and  also  the  spring  appa- 
ratus for  bunion  (Fig.  83)  for  two  or 
three  months  so  as  to  keep  the  toe  in 
its  abducted  position ;  sometimes  the 
result  is  so  good  that  a  boot  with  a  toe- 
post  is  all  that  is  necessary.  The  boots 
must  be  constructed  on  the  principles 
laid  down  on  p.  281.  In  about  three  or 
four  months  after  the  operation  the 
patient  is  generally  able  to  discard  all 
apparatus,  and  there  is  no  fear  of  recur- 
rence if  proper  boots  be  worn.  The  re- 
sults of  the  operations  are  extremely 
satisfactory.  It  is  important  to  remem- 
ber, however,  that  the  joint  is  necessarily  opened,  and  that  strict  asepsis 
is  therefore  of  primary  importance. 

Excision  of  the  head  of  the  first  metatarsal  has  been  employed  for  this 
affection  and  is  strongly  advocated  by  some.  It  should  be  borne  in  mind, 
however,  that  removal  of  the  head  of  the  first  metatarsal  impairs  the 
walking  power  of  the  foot  very  considerably,  and,  in  view  of  the  satis- 
factory results  obtained  by  the  procedures  already  described,  we  are 
inclined  to  think  that  such  an  operation  is  only  necessary  when  there 


FIG.  85. — THE  BONES  OF  THB 
GREAT  TOE  IN  A  CASK  OF  HALLUX 
VALGUS.  The  black  line  indicates 
the  amount  of  bone  that  must  be 
cut  away. 


286  DEFORMITIES 

are  extensive  alterations  in  the  head  of  the  metatarsal  bone  such  as  lipping 
and  outgrowths.  When  this  procedure  is  carried  out,  some  of  the  soft 
tissues  should  be  interposed  between  the  divided  ends  of  the  bones  in 
order  to  prevent  osseous  ankylosis  from  taking  place. 

The  surgeon  is  sometimes  caUed  upon  to  treat  a  bunion  in  which 
suppuration  has  occurred.  These  cases  should  be  treated  first  upon  the 
general  principles  applying  to  suppurative  bursitis  (see  Vol.  II.).  The 
cavity  should  be  laid  open  freely  and  drained,  and  dressings  suitable  to 
the  degree  and  character  of  the  inflammation  should  be  applied.  It  is  out 
of  the  question  to  adopt  the  operative  procedures  just  described  for  the 
radical  cure  of  the  bunion  until  the  wound  has  been  soundly  healed  for 
some  weeks  ;  its  cure  should  then  be  undertaken  upon  the  lines  already 
laid  down. 

In  some  cases  no  true  acute  suppuration  occurs,  but  a  sinus  forms, 
leading  into  the  joint  and  discharging  a  serous  or  synovial  fluid.  In 
these  cases  there  are  usually  extensive  osteo-arthritic  changes,  and 
healing  will  not  be  obtained  until  the  head  of  the  metatarsal  bone  has 
been  removed. 

HALLUX   FLEXUS— HALLUX  RIGIDUS. 

In  hallux  flexus  the  great  toe  is  bent  somewhat  downwards  towards 
the  plantar  surface ;  in  hallux  rigidus  it  is  quite  straight ;  in  either  case 
any  attempt  to  extend  it  gives  rise  to  considerable  pain.  The  result  is 
that  the  patient  cannot  walk  with  the  foot  in  the  normal  position  owing 
to  the  necessity  of  avoiding  movement  of  the  toe ;  generally  he  walks 
upon  the  inner  border  of  the  foot,  which  is  kept  in  the  abducted  position. 
The  deformity  is  associated  with  flat  foot,  and  in  many  cases  appears  to  be 
the  direct  result  of  it. 

Hallux  rigidus  is  described  as  existing  alone.  Undoubtedly  cases  are 
met  with  in  which  the  great  toe  is  painful  and  stiff  but  not  flexed  ;  flexion 
will  invariably  develop  later,  however,  if  the  affection  be  left  untreated. 
We  shah1  therefore  describe  the  treatment  of  the  two  affections  together. 

TREATMENT. — In  the  early  stages  a  Whitman's  spring,  combined 
with  the  exercises  recommended  for  flat  foot  (see  p.  303),  will  often  cause 
the  patient  to  lose  his  pain  rapidly ;  the  stiffness  of  the  joint  then  dis- 
appears, and  locomotion  is  no  longer  painful.  In  the  more  severe  cases, 
however,  it  may  be  necessary  to  combine  division  of  the  lateral  ligaments 
of  the  joint,  and  possibly  also  of  the  plantar  fascia,  with  the  treatment 
of  the  flat  foot. 

Marked  alterations  take  place  in  the  joint  and  the  ligaments  in  the 
more  severe  cases,  however,  so  that  no  real  improvement  is  effected  in 
the  toe,  although  the  flat  foot  may  be  remedied.  These  cases  therefore 
call  for  some  radical  operation  which  may  take  the  form  of  removal 
of  the  base  of  the  first  phalanx  or  the  head  of  the  metatarsal  bone, 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     287 

the  aim  of  the  operation  being  to  allow  the  joint  to  be  brought  straight 
by  removing  one  of  the  articular  surfaces  which  enter  into  it.  The 
operation  usually  done  is  removal  of  the  head  of  the  metatarsal ; 
the  great  objection  to  it  is,  however,  that  this  structure  plays  a  most 
important  part  in  proper  progression,  and  its  removal  is  likely  to  interfere 
seriously  with  the  usefulness  of  the  foot.  In  bad  cases,  however,  it  may 
have  to  be  done. 

A  perfectly  good  result,  however,  can  be  obtained  in  the  less  severe 
cases  that  nevertheless  call  for  operative  interference,  by  removing  the 
base  of  the  first  phalanx.  The  operation  is  done  through  an  incision 
about  an  inch  in  length,  parallel  and  a  little  internal  to  the  inner  border 
of  the  extensor  tendon.  The  periosteum  is  detached  from  the  first 
phalanx  by  a  suitable  rugine,  and  the  base  of  the  bone  is  then  nipped 
off  with  a  strong  pair  of  cutting  pliers.  This  allows  the  toe  to  be  brought 
straight  without  any  tension.  The  periosteum  and  any  adjacent  soft 
tissues  are  then  turned  in  so  as  to  cover  the  raw  bony  surface  and  thus 
to  prevent  the  occurrence  of  ankylosis. 

The  wound  is  closed  without  a  drainage-tube,  and  the  toe  fixed  to  a 
plantar  splint  so  padded  that  the  toe  is  a  little  hyper-extended.  When  the 
wound  has  healed,  the  toe  and  front  part  of  the  foot  should  be  put  up  in  a 
silicate  bandage,  applied  while  the  arch  of  the  foot  is  restored  as  much  as 
possible  by  bending  the  metatarsal  bones  downwards  ;  this  leads  to  an 
improvement  in  the  flat  foot,  whilst  the  parts  are  being  kept  at  rest  for 
proper  consolidation  to  occur.  After  about  six  weeks  the  patient  may 
be  provided  with  a  Whitman's  spring  (see  Fig.  91),  and  allowed  to  walk. 
The  results  are  usually  good ;  locomotion  is  perfectly  satisfactory  and 
quite  painless. 

ANTERIOR  METATARSALGIA,  OR  MORTON'S  NEURALGIA. 

This  important  condition  was  first  fully  described  by  Morton,  of  Phila- 
delphia, after  whom  it  is  named.  It  is  a  painful  affection  of  the  anterior 
part  of  the  foot,  usually  in  the  neighbourhood  of  the  heads  of  the  third 
and  fourth  metatarsal  bones.  The  pain  is  neuralgic  in  character  and 
is  referred  to  the  plantar  aspect ;  it  may  be  so  severe  that  the  patient 
is  unable  to  walk  or  bear  any  pressure  upon  the  affected  region.  It  is 
generally  impossible  for  the  patient  to  wear  narrow  shoes,  and  in  some 
cases  boots  or  shoes  of  any  kind  cannot  be  tolerated.  It  is  usually 
noticed  that  the  pain  diminishes  or  ceases  entirely  as  soon  as  the  shoes 
are  taken  off  and  the  foot  is  elevated. 

Callosities  may  form  upon  the  sole  beneath  the  head  of  the  fourth 
metatarsal ;  sometimes  they  also  form  beneath  the  head  of  the  third,  or 
even  the  second,  and  then,  to  avoid  pain,  the  patient  bears  his  weight  upon 
the  inner  border  of  the  foot,  and  avoids  putting  any  pressure  upon  the 
outer  side  at  all.  These  callosities,  besides  adding  considerably  to  the 


288  DEFORMITIES 

pain,  are  liable  to  attacks  of  inflammation,  which  cripple  the  patient  still 
further.  If  the  foot  be  looked  at  from  the  dorsal  surface,  when  the  toes 
are  flexed  towards  the  sole,  the  heads  of  the  metatarsal  bones  in  the 
neighbourhood  of  which  the  pain  is  most  marked  are  seen  to  be  on  a  lower 
level  than  the  rest.  This  is  apparently  due  to  relaxation  of  the  ligaments 
that  bind  the  heads  of  the  metatarsal  bones  together.  The  pain  is  sup- 
posed by  Morton  to  be  due  to  a  lateral  compression  of  the  foot,  which 
causes  the  head  of  the  fifth  metatarsal  to  compress  branches  of  the  external 
plantar  nerve  against  the  head  of  the  fourth.  Although  this  explanation 
may  be  the  correct  one  in  some  cases,  in  others  the  pain  is  probably  due 
to  the  undue  pressure  exerted  upon  the  sole  by  the  head  of  the  bone  which 
has  become  displaced  downwards,  from  its  normal  position. 

The  affection  not  infrequently  follows  upon  injury,  but  cases  un- 
doubtedly occur  in  which  there  is  no  history  of  any  injury,  and  these  are 
generally  the  ones  in  which  narrow  boots  are  worn  and  bring  about  lateral 
compression  of  the  metatarsal  bones.  The  condition  is  often  associated 
with  flat  foot,  and  sometimes  the  whole  trouble  disappears  when  the  de- 
pression of  the  arch  is  corrected,  It  occurs  more  frequently  in  women 
than  in  men. 

TREATMENT. — This  may  be  divided  into  palliative  and 
operative,  the  majority  of  cases  yielding  to  the  former. 

Palliative  Treatment. — The  first  essential  is  that  the  patient  should 
wear  properly  fitting  boots.  They  should  be  sufficiently  wide  and  should 
everywhere  afford  proper  support  to  the  foot.  They  should  be  made  to  a 
plaster  cast  of  the  foot,  as  it  is  otherwise  difficult  to  combine  proper 
support  with  avoidance  of  undue  pressure.  In  addition,  a  Whitman's 
spring  (see  p.  303)  should  be  worn  to  support  the  arch  of  the  instep,  and  the 
tiptoe  exercises  recommended  for  flat  foot  (see  p.  302)  may  with  advantage 
be  prescribed-  so  as  to  strengthen  the  structures  in  the  sole.  Massage 
is  of  value,  and  douching  the  foot  is  also  useful.  An  anodyne  application 
such  as  belladonna,  to  the  sole  of  the  foot,  may  be  called  for  to  relieve 
pain.  The  majority  of  the  early  cases  treated  in  this  manner  yield 
satisfactory  results. 

Operative  Treatment. — In  bad  cases,  however,  in  which  the  affection 
has  lasted  a  long  time,  no  permanent  benefit  results  from  any  of  these 
procedures,  and  it  is  necessary  to  have  recourse  to  operative  interference. 
The  procedure  which  has  yielded  the  best  results  up  to  the  present  time 
is  removal  of  the  head  of  the  metatarsal  bone  which  is  unduly  depressed  ;  in 
most  cases  this  is  the  fourth,  but  sometimes  it  is  necessary  to  remove 
the  head  of  the  third  as  well.  The  operation  is  performed  by  making  a 
longitudinal  incision  upon  the  dorsal  aspect  of  the  foot  over  the  head  of 
the  affected  metatarsal  bone,  parallel  to  but  on  one  side  of  the  extensor 
tendon.  The  edges  of  the  incision  are  retracted,  the  tendon  is  hooked 
aside,  and  the  soft  parts  are  separated  from  the  head  of  the  bone  with  a 
periosteum  detacher.  The  neck  of  the  metatarsal  is  then  divided  by 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES      289 

cutting  pliers  or  a  fine  saw,  and  the  head  is  removed  after  division  of  the 
ligaments  attaching  it  to  the  neighbouring  bones.  The  patient  should 
lie  up  for  about  three  weeks  after  the  operation.  After  the  operation  he 
must  wear  properly  constructed  boots  made  to  a  plaster  cast  of  the  foot. 
Should  flat  foot  be  present,  he  should  also  be  fitted  with  an  artificial  support 
to  the  instep. 

CONTRACTIONS  OF  THE  FINGERS. 

The  majority  of  contractions  met  with  in  the  fingers  are  acquired. 
There  is  a  congenital  condition  in  which  the  little  finger  is  flexed,  and  is  in 
a  position  similar  to  that  assumed  by  a  hammer  toe.  The  finger  is 
flexed  at  the  first  interphalangeal  joint,  whilst  the  second  and  third 
phalanges  are  in  the  same  straight  line,  or  the  terminal  phalangeal 
joint  may  be  hyper-extended. 

TREATMENT. — In  slight  cases  the  deformity  passes  practically 
unnoticed,  and  does  not  call  for  treatment.  When,  however,  the  de- 
formity is  extreme,  or  when  it  is  necessary  to  remedy  it  in  order  to  enable 
the  patient  to  carry  out  some  particular  form  of  manual  labour,  and 
especially  when  the  right  hand  is  affected,  the  treatment  should  be  con- 
ducted on  lines  practically  identical  with  that  recommended  for  hammer 
toe  (see  p.  277).  In  the  slighter  cases,  division  of  the  anterior  and  lateral 
ligaments  may  be  performed,  and  the  finger  afterwards  kept  on  a  splint 
both  night  and  day  for  four  to  six  weeks  ;  it  may  then  be  left  off  during 
the  day,  and  a  narrow  posterior  splint  applied  during  the  night.  The 
results,  however,  are  generally  very  unsatisfactory ;  the  deformity  is 
congenital,  and  unless  treatment  be  commenced  at  an  early  age,  the 
joint  surfaces  are  so  altered  that  restoration  of  function  is  rarely  perfect, 
and  it  is  a  question  whether  it  is  worth  the  patient's  while  to  go  through 
a  prolonged  course  of  treatment  by  splints  when  there  is  a  great  chance  of 
the  deformity  recurring. 

The  simplest  plan  in  these  cases  is  to  perform  an  operation  similar 
to  that  employed  for  the  cure  of  hammer  toe — namely,  the  removal  of 
the  head  of  the  first  phalanx.  This  is  easily  done  through  a  vertical  in- 
cision upon  the  inner  side  of  the  little  finger  exposing  the  neck  of  the 
bone,  which  is  divided  by  cutting  pliers,  and  the  head  removed.  The 
wound  is  stitched  up,  the  finger  brought  straight  and  kept  upon  a  splint 
for  six  weeks,  when  passive  movement  is  begun  and  the  splint  discarded. 


DUPUYTREN'S  CONTRACTION. 

This  affection  is  primarily  due  to  a  contraction  of  the  digital  processes 
of  the  palmar  fascia,  the  main  body  of  that  structure  usually  being  only 
affected  secondarily.  In  typical  cases  the  affection  runs  an  extremely  slow 
course.  It  is  generally  symmetrical  and  usually  first  affects  the  ring 


290  DEFORMITIES 

finger  on  each  side ;  the  little  finger  is  next  affected,  and  in  bad  cases 
the  remaining  fingers  may  become  attacked  one  after  another,  but  in 
any  case  the  ring  finger  is  the  most  markedly  contracted.  The  condition 
is  more  frequently  met  with  in  men  than  in  women,  and  generally  attacks 
those  over  fifty  years  of  age.  It  is  not  uncommonly  associated  with 
gout,  rheumatism,  or  osteo-arthritis.  In  some  cases  it  is  said  to  be 
hereditary,  but  whether  it  is  that  the  tendency  to  this  particular  de- 
formity is  hereditary,  or  whether  it  is  due  to  the  associated  hereditary 
gouty  condition,  it  is  hard  to  say.  It  is  a  noteworthy  fact  that  the  con- 
traction is  particularly  prone  to  occur  in  persons,  such  as  carpenters  and 
the  like,  whose  occupations  necessitate  considerable  and  repeated  pressure 
by  tools  and  instruments  against  the  palm  of  the  hand. 

PATHOLOGY. — The  essential  alteration  is  thickening  and  shorten- 
ing of  the  palmar  fascia  and  the  various  processes  of  fibrous  tissue  given 
off  by  it.  These  changes  are  mainly  confined  to  the  digital  processes,  in 
the  early  stages  at  any  rate,  and  the  result  of  their  shortening  is  flexion  of 
the  finger  at  the  metacarpo-phalangeal  joint.  As  the  contraction  becomes 
more  marked  there  is  flexion  of  the  first  interphalangeal  joint  as  well ; 
the  second  generally  remains  unaffected,  the  two  terminal  phalanges 
being  nearly  in  the  same  straight  line.  Still  later  in  the  disease,  the 
thickening  affects  the  body  of  the  palmar  fascia,  which  then  shows 
irregular  masses  of  fibrous  tissue  upon  it.  The  thickening  also  affects 
the  small  fibrous  bands  which  pass  from  the  surface  of  the  fascia  to  the 
skin,  and  the  result  is  that  the  skin  becomes  bound  down  to  the  palmar 
fascia  and  much  puckered,  so  that  there  are  often  hard  horny  ridges  and 
irregular  thickenings  in  the  palm,  which  are  due  to  the  thickened  fibrous 
slips  with  the  adherent  skin  over  them.  It  is  important  to  bear  this 
point  in  mind  when  treating  the  condition.  There  is  no  primary  con- 
traction of  the  flexor  tendons,  and  it  is  almost  invariably  found  that  the 
tendons  offer  no  bar  to  the  re-position  of  the  finger  after  all  the  fascial 
structures  have  been  divided.  When,  however,  the  affection  has  lasted 
for  a  long  tune  there  is  secondary  contraction  of  the  ligaments  of  the 
articulations  that  have  been  kept  flexed,  and  these  structures  may  require 
division  before  the  fingers  can  be  straightened. 

TREATMENT. — Nothing  but  operative  interference  is  likely  to  be 
successful.  Attempts  to  prevent  or  overcome  the  deformity  by  stretch- 
ing the  fascia  by  splints,  elastic  traction,  and  the  like,  cause  pain,  irritate 
the  fascia,  and  lead  to  a  rapid  increase  in  the  contraction.  At  the  same 
time  operative  treatment  is  not  always  so  satisfactory  in  its  results  as 
could  be  wished,  because  there  is  a  tendency  to  the  reproduction  of  the 
deformity. 

Fibrolysin  is  often  employed  for  this  condition,  and  good  results  have 
been  reported.  Its  use  is,  however,  not  free  from  danger,  especially  in  old 
people,  and  cases  of  fatal  purpura  have  been  reported.  We  have  seen  no 
decided  benefit  from  it  in  any  of  our  cases. 


INDICATIONS.— The  following  are  the  points  that  would  lead 
the  surgeon  to  employ  certain  operations  in  particular  cases,  (i)  When 
the  fingers  are  not  bent  beyond  a  right-angle,  subcutaneous  division  is 
usually  as  satisfactory  a  method  as  any  other.  (2)  When  there  are  only 
one  or  two  tight  bands,  when  the  skin  is  not  markedly  puckered,  and 
when  the  fingers  are  not  greatly  contracted,  the  best  method  is  to  remove 
the  fascia  by  careful  dissection — the  second  procedure  described.  (3)  In 
very  advanced  cases,  in  which  the  fingers  are  tightly  flexed  into  the  palm, 
this  latter  operation  cannot  be  performed,  because  it  is  impossible  to 
get  proper  access  to  the  palm  so  as  to  make  the  requisite  incisions.  The 
best  treatment  then  is  to  get  the  finger  as  straight  as  possible  by  means 
of  subcutaneous  division  in  the  first  instance.  As  a  rule,  however,  this 
will  not  allow  the  finger  to  come  quite  straight  because  the  skin  itself 
is  contracted,  and  therefore  a  further  operation  must  be  combined  with 
subcutaneous  division,  so  as  to  complete  the  straightening  of  the  finger. 
The  two  operations,  however,  should  be  done  at  different  times.  Sub- 
cutaneous division  endangers  the  vitality  of  the  skin  at  various  points, 
which,  however,  rarely  sloughs,  unless  too  great  pressure  be  brought 
to  bear  on  it ;  but  if  another  operation  were  done  immediately  after  it, 
the  damaged  portions  of  the  skin  would  almost  certainly  die.  Hence 
sufficient  time  must  be  allowed  to  elapse  between  the  subcutaneous  and 
the  open  operation  to  allow  these  damaged  portions  of  skin  to  recover 
properly,  and  during  this  time  the  fingers  should  be  kept  somewhat 
extended  on  a  splint ;  three  weeks'  interval  is  usually  enough.  The  V 
operation  is  to  be  preferred  in  these  cases.  It  is  useless  to  attempt  to 
dissect  out  the  contracted  fascia  soon  after  subcutaneous  division  has 
been  done,  because  all  the  tense  bands  have  been  divided,  and  they 
cannot  be  defined  properly. 

Subcutaneous  division  of  the  palmar  fascia  and  the  processes 
connected  with  it  is  the  method  most  commonly  employed,  but  it  is  not 
always  the  most  satisfactory.  Before  performing  this,  or  indeed  any 
operation  upon  the  palm,  steps  should  be  taken  to  soften  the  skin  as 
much  as  possible  for  several  days  beforehand.  The  palm  should  be 
subjected  to  frequent  soakings  in  hot  water,  washings  with  soft  soda-soap, 
and  kneadings  with  glycerine,  vaseline,  or  lanoline.  The  operation  itself 
must  be  carried  out  with  scrupulous  regard  to  antiseptic  precautions  (see 
p.  100).  A  tenotomy  knife  with  a  very  small  cutting  blade  is  cautiously 
insinuated  flatwise  between  the  skin  and  the  fascia  ;  the  cutting  edge  is 
then  turned  towards  the  fascia,  and  the  contracted  bands  (which  are 
rendered  tense  by  traction  upon  the  finger)  are  divided  one  after  the 
other.  As  a  rule  a  good  many  punctures  are  required,  and  the  fascia 
must  be  nicked  in  all  directions.  The  principal  seat  of  division  will  be 
in  the  digital  processes,  so  that  the  punctures  are  generally  made  between 
the  transverse  crease  of  the  palm  and  the  line  of  the  first  interphalangeal 
joint.  When  there  is  also  puckering  of  the  skin,  the  knife  should  be 

u  2 


292  DEFORMITIES 

swept  flatwise  between  the  skin  and  the  fascia  so  as  to  free  the  adherent 
portions.  The  operation  should  be  carried  out  with  the  greatest  thorough- 
ness, and  half  to  three-quarters  of  an  hour  may  be  consumed  in  a  systematic 
endeavour  to  find  and  divide  all  the  tight  bands  of  fascia  present.  It  is 
useless  to  attempt  to  cure  the  affection  by  simply  dividing  the  fascia 
in  one  or  two  spots. 

After  all  the  tense  fascial  bands  have  been  divided,  the  finger  is 
extended  fully  and  the  palm  kneaded,  so  as  to  rupture  any  fibres  that 
may  have  escaped  division.  In  doing  this  it  is  often  found  necessary  to 
re-introduce  the  tenotomy  knife  and  divide  some  tight  band  that  had 
not  been  noticed  previously.  A  pad  of  antiseptic  gauze  is  then  placed 
in  the  palm,  and  the  hand  put  upon  a  palmar  splint  (see  Fig.  86)  which 
is  padded  especially  thickly  beneath  the  fingers,  so  as  to  produce  good 
extension  when  the  hand  is  bandaged  to  it.  When  the  contraction  is 


FIG.  86. — DUPUYTREN'S  CONTRACTION.  SPLINT  FOR  USE  IMMEDIATELY  AFTER  SUB- 
CUTANEOUS DIVISION  OF  THE  FASCIA.  This  is  made  of  light  metal  well  padded,  and 
can  be  bent  somewhat  should  it  be  difficult  to  get  the  finger  straight  immediately  after 
the  operation  ;  it  can  then  be  straightened  gradually  as  the  finger  stretches.  (After 
Adams.) 

great  and  the  skin  is  much  thickened,  however,  the  fingers  must  not  be 
stretched  unduly,  partly  because  considerable  pain  would  be  caused,  and 
partly  because  the  skin  might  slough,  since  its  vitality  has  been  interfered 
with  by  the  operation.  In  these  cases,  therefore,  it  is  better  to  leave  the 
fingers  somewhat  flexed  for  the  first  twenty-four  or  forty-eight  hours, 
and  then  to  increase  the  extension  gradually  by  readjusting  the  splint 
and  increasing  the  padding,  or  by  fastening  the  metacarpals  to  the  splint 
by  an  elastic  bandage,  which  will  gradually  press  the  palm  down  flat  upon 
the  splint,  the  fingers  being  separated  from  it  by  the  padding.  In  a 
week  or  so  the  fingers  should  have  become  rather  over-extended. 

For  the  first  month  the  splint  must  be  worn  night  and  day ;  then  a 
dorsal  splint  may  be  substituted  for  it,  taking  its  purchase  from  the 
lower  part  of  the  forearm,  and  fastened  round  the  latter  with  suitable 
straps.  The  splint  should  extend  over  the  inner  side  of  the  dorsum  of 
the  hand  as  far  down  as  the  knuckles,  and  from  this  main  piece  separate 
prolongations  arise,  one  for  each  of  the  affected  fingers.  These  pro- 
longations are  bent  somewhat  backwards  from  the  main  portion  of  the 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     293 

splint,  so  that  when  the  affected  fingers  are  fastened  to  them  by  means  of 
elastic  bands  they  are  in  a  position  of  slight  hyper-extension  (see  Fig.  87)  ; 
the  thumb  and  any  fingers  unaffected  are  left  free,  so  that  the  patient 
can  use  the  hand  to  a  certain  extent.  The  splint  should  be  worn  night 
and  day  for  at  least  six  weeks,  but  it  should  be  taken  off  two  or  three 
times  daily  so  as  to  allow  the  fingers  to  be  exercised,  and  massage  and 
passive  movement  to  the  palm  and  finger  to  be  practised  ;  at  the  end  of 
six  weeks  it  may  be  worn  only  at  night.  The  use  of  the  splint  at  night 
should  not  be  given  up  for  at  least  six  months  after  the  operation  ;  at 
the  end  of  that  time  it  can  generally  be  abandoned  entirely.  When 
there  is  much  stiffness  of  the  joints  and  considerable  rigidity  of  the 
skin,  with  hard  horny  thickenings,  a  course  of  treatment  by  superheated 
air  is  useful  in  getting  the  part  supple  ;  the  fingers  should  be  repeatedly 
moved  and  the  palm  kneaded  with  glycerine  or  lanoline  so  as  to  soften 
the  skin. 


FIG.  87. — DUPUYTREN'S  CONTRACTION.  SPLINT  FOR  MAINTAINING  FULL  EXTENSION 
AFTER  SUBCUTANEOUS  DIVISION  OF  THE  FASCIA.  This  splint  is  applied  on  the  dorsal 
surface  of  the  hand,  and  takes  purchase  from  the  wrist.  Hence  powerful  extension 
of  the  fingers  can  be  got.  The  finger  prolongations  (which  will  vary  in  number 
according  to  the  fingers  affected)  can  be  bent  backwards  if  necessary,  as  the  splint  is 
made  of  malleable  metal. 

The  usual  result  of  subcutaneous  division  of  the  fascia  carried  out  in 
this  thorough  manner  is  that  the  patient  remains  well  for  three  or  four 
years,  and  then  the  contraction  recurs  and  a  second  operation  is  required, 
the  results  of  which  may  be  as  satisfactory  as  those  of  the  former  one. 
No  permanent  cure,  however,  can  be  looked  for  by  this  method. 

The  open  operations  of  most  value  are  removal  of  the  whole 
of  the  contracted  fascia,  and  division  of  the  fascia  and  the  skin  by  a 
V-shaped  incision  without  removal  of  any  portion  of  the  fascia,  so  as  to 
enable  the  finger  to  be  extended. 

Excision  of  the  Contracted  Fascia — After  the  skin  has  been  softened 
as  much  as  possible  in  the  manner  described  above,  it  is  disinfected,  and 
a  vertical  incision  is  made  over  the  contracted  band  extending  from  the 
root  of  the  finger  (or  further  down,  if  necessary)  to  its  upper  limit ;  then 
transverse  incisions  are  made  at  each  end  of  the  vertical  incision,  so  that 
rectangular  flaps  of  skin  can  be  turned  out  on  each  side  (see  Fig.  88). 
Any  marked  horny  indurations  in  the  skin  over  the  contracted  band 
should  be  included  in  an  elliptical  incision,  and  removed  at  the  same  time. 
When  the  finger  is  much  flexed,  considerable  difficulty  may  be  experienced 


294 


DEFORMITIES 


in  turning  aside  the  skin  over  the  contracted  fascia,  and  it  is  a  good  plan 
to  pass  a  tenotomy  knife  between  the  skin  and  the  fascia  before  making 
the  skin  incision  so  as  to  separate  the  two  structures  from  one  another  ; 
this,  however,  should  only  be  done  in  one  or  two  places,  and  then  very 
cautiously,  because  it  endangers  the  vitality  of  the  skin  to  a  certain 
extent.  After  the  flaps  are  turned  aside,  the  contracted  band  of  fascia 
is  dissected  out,  together  with  all  the  slips  going  to  the  fingers.  Sub- 
sequently the  contracted  ligaments  around  the  joint  may  be  divided 


FIG.  88. — EXCISION  OF  THE  PALMAR  FASCIA.  The  left-hand  figure  shows  the  in- 
cision made  over  the  contracted  band  of  fascia  that  is  to  be  excised.  In  the  right-hand 
figure  (drawn  to  a  larger  scale),  the  flaps  are  shown  turned  aside,  and  the  slips  of  con- 
tracted fascia  requiring  to  be  dissected  out  are  seen. 

with  a  tenotomy  knife,  if  this  should  be  found  necessary  in  order 
to  bring  the  finger  straight.  This  operation  can  sometimes  be  per- 
formed under  local  anaesthesia,  the  whole  of  the  tissues  around  the  con- 
tracted band  being  thoroughly  infiltrated  with  the  analgesic  solution. 
The  patient  can  then  often  help  materially  by  moving  the  fingers  so  as 
to  make  the  various  bands  stand  out  one  after  the  other. 

It  is  often  difficult  to  approximate  the  edges  of  the  wound  after 
the  operation,  especially  when  a  portion  of  the  skin  has  been  excised. 
This  is  largely  due  to  the  fact  that  the  skin  is  contracted  in  both  the 
transverse  and  the  longitudinal  directions.  The  skin  should  be  sutured 
as  closely  as  possible,  and  immediate  skin-grafting  should  be  employed 
for  any  raw  surface  left.  It  is  imperative  that  no  granulating  surface 


DEFORMITIES  AFFECTING  THE  FINGERS  AND  TOES     295 

should  remain,  as  otherwise  the  scar  which  forms  will  materially  hamper 
the  progress  of  the  case.  If  skin-grafting  be  used,  a  single  graft  should 
be  employed  if  possible.  The  after-treatment  is  similar  to  that  for  sub- 
cutaneous division. 

In  the  other  operation,  a  V-shaped  incision  is  made  in  the  palm 
and  carried  through  both  skin  and  fascia.  The  apex  of  the  V  should 
be  situated  in  the  long  axis  of  the  finger  which  is  most  contracted  and 
just  above  the  transverse  crease  of  the  palm  ;  from  this  point  incisions 
are  carried  downwards  into  the  palm  on  each  side,  diverging  from  each 


FIG.  89. — THE  v  OPERATION  FOR  DUPUYTREN'S  CONTRACTION.  A  shows  the 
hand  after  the  incision  has  been  made  through  the  fascia,  and  the  finger  straightened. 
The  raw  surface  thus  left  is  closed  by  employing  sutures  in  the  manner  shown  in  B. 
There  is  often  a  small  raw  surface  left  at  the  junction  of  the  three  limbs  of  the  Y  ;  this 
should  be  covered  by  a  skin-graft 

other  and  ending  about  half  an  inch  from  the  web  (see  Fig.  89,  .4).  The 
incisions  are  carried  through  skin  and  fascia,  the  latter  being  completely 
divided,  and  no  attempt  is  made  to  separate  the  two  structures.  The 
finger  can  then  be  extended  without  tearing  or  dividing  any  tight  bands. 
After  the  finger  has  been  brought  straight,  a  large  triangular  wound  is 
left  in  the  palm,  but  this  may  be  stitched  together  if  the  skin  be  supple, 
so  that  little  or  no  raw  surface  is  left.  The  sides  of  the  wound  are  ap- 
proximated, and  the  apex  of  the  V  fits  in  between  them  where  they  diverge 
lower  down  (see  Fig.  89,  B),  so  that  there  may  be  complete  closure  of 
the  wound.  When  the  skin  is  not  sufficiently  elastic,  a  certain  amount 
of  raw  surface  is  left,  which  should  be  covered  immediately  with  a 
single  skin-graft. 

The  preliminary  treatment  of  the  palm,  in  order  to  render  it  supple, 


296 


DEFORMITIES 


is  the  same  as  before,  and  the  after-treatment  is  identical  with  that  for 
the  subcutaneous  operation  (see  p.  293).  The  immediate  result  of  this 
operation  is  usually  satisfactory,  but  here,  as  in  the  former  case,  the 
contraction  tends  to  recur. 


CONTRACTIONS  AFTER  BURNS. 

It  is  not  uncommon,  especially  in  young  children,  to  meet  with  con- 
traction of  the  fingers  as  a  result  of  the  cicatricial  contraction  following 


A  B 

FIG.  90. — OPERATION  FOR  CONTRACTED  FINGER  AFTER  A  BURN.  A  shows  the  in- 
cisions for  raising  the  lateral  flaps ;  the  portion  between  them  is  dissected  out.  B 
shows  the  finger  straightened  after  this  has  been  done.  The  flaps  are  sutured  together 
throughout  most  of  their  extent,  the  triangular  raw  surfaces  left  above  and  below 
being  covered  by  skin-grafts. 

upon  burns.  The  condition  is  of  the  greatest  importance  because  of  the 
resulting  uselessness  of  the  hand.  The  burns  are  generally  produced  by 
grasping  something  red-hot,  such  as  a  poker,  or  falling  on  to  the  bars  of 
a  grate,  and  burning  the  palmar  surface  of  the  fingers.  The  result  is  a 
granulating  wound  which,  when  cicatrisation  is  complete,  gives  rise  to 
ridges  of  cicatricial  tissue  extending  from  the  palmar  surface  of  the  tips 
of  the  fingers  to  the  palm,  the  fingers  becoming  flexed  and  rigid  from  the 
contraction  of  the  scar. 

TREATMENT. — The  deformity  is  difficult  to  remedy.  If  the 
bands  be  divided  transversely,  recurrence  of  the  contraction  will  take 
place  almost  inevitably  as  the  wound  heals,  and  the  deformity  will  be 


CONGENITAL  ELEVATION  OF  THE  SCAPULA  297 

reproduced.  Transverse  division  of  the  cicatricial  band,  followed  by 
immediate  skin-grafting  of  the  raw  surface,  also  fails  to  give  a  satisfactory 
result.  The  best  treatment  is  to  dissect  out  all  the  cicatricial  tissue  on 
the  front  of  the  finger,  and  then  to  straighten  the  latter.  A  considerable 
time — at  least  a  year — should  be  allowed  to  elapse  between  the  com- 
pletion of  cicatrisation  and  the  operation  in  order  to  allow  the  scar  to 
become  as  supple  as  possible.  The  operation  may  be  done  as  follows. 
An  incision  is  carried  from  end  to  end  of  the  finger  upon  each  side  of  the 
central  cicatrix,  and  as  near  it  as  possible.  These  incisions  are  curved 
outwards  at  each  end,  so  that  each  one  nearly  reaches  the  dorsum  (see 
Fig.  90,  A).  In  this  way  a  flap  is  marked  out  on  each  side  of  the  finger, 
and  these  are  dissected  up  so  as  to  expose  all  the  cicatricial  tissue.  The 
central  cicatrix  and  the  cicatricial  tissue  surrounding  it  are  then  dissected 
out,  when  generally  the  finger  can  be  brought  straight,  although  it  may 
be  necessary  to  divide,  in  addition,  some  of  the  various  ligaments  around 
the  joints  when  the  contraction  has  lasted  for  a  long  time.  After  the 
finger  has  been  straightened,  the  flaps  may  be  made  to  meet  in  the  middle 
line  throughout  the  greater  part  of  their  extent,  a  triangular  raw  space 
being  left  at  either  end  which  must  be  covered  with  a  skin-graft  (see 
Fig.  90,  B).  The  advantage  of  this  plan  over  that  of  simple  transverse 
division  of  the  cicatrix  followed  by  skin-grafting  is  that  the  raw  surface 
is  covered  by  skin  over  the  centre  of  the  finger  corresponding  to 
the  middle  phalanx,  so  that  no  contraction  occurs.  It  is  not  a  matter 
of  great  moment  should  any  contraction  occur  where  the  skin-grafts 
have  been  applied.  In  order  to  guard  against  the  tendency  to  contraction 
still  further,  the  hand  should  be  put  upon  an  anterior  splint,  with  the 
finger  hyper-extended,  until  the  wound  has  healed.  After  about  a 
fortnight's  interval,  a  back  splint  should  be  substituted,  similar  to  that 
described  for  use  in  Dupuytren's  contraction  (see  Fig.  87),  and  to  this 
the  finger  or  fingers  are  fastened  back  day  and  night  for  six  or  eight 
weeks.  At  the  end  of  the  first  fortnight,  when  the  wound  has  healed, 
the  splint  should  be  removed  three  or  four  times  a  day,  and  careful 
massage  and  passive  movements  carried  out.  After  eight  weeks  the 
splint  is  left  off  during  the  day,  and  the  patient  encouraged  to  use  the 
fingers  constantly.  The  splint,  however,  should  be  worn  at  night  for 
six  or  eight  months  longer. 

CONGENITAL  ELEVATION  OF  THE  SCAPULA. 

In  this  deformity  the  scapula  is  drawn  upwards  upon  the  thoracic 
wall,  by  contraction  of  the  muscles  at  the  back  of  the  neck,  gliding 
over  the  upper  ribs  until  its  superior  angle  can  be  felt  projecting  into 
the  posterior  triangle  of  the  neck\  A  cursory  examination  gives  the 
impression  that  there  is  a  well-marked  exostosis  at  this  point,  but  careful 
examination  and  radiograms  show  that  this  is  not  the  case,  the  unusual 


298  DEFORMITIES 

appearance  being  produced  by  the  altered  position  of  the  scapula.  In 
many  cases  the  shape  of  the  scapula  is  unaltered,  but  in  others  it  is  elon- 
gated in  a  direction  parallel  to  the  spine,  and  in  rare' instances  there  is  a 
separate  ossicle  connecting  the  vertebral  border  with  the  spines  of  the 
dorsal  vertebrae.  The  muscles  which  elevate  the  scapula  are  con- 
tracted and  thickened,  a  point  specially  noticeable  in  the  trapezius  where 
it  bounds  the  posterior  triangle.  The  lower  portion  of  the  trapezius 
and  the  muscles  which  retract  the  scapula  are  thin  and  wasted.  This 
deformity  does  not  give  rise  to  much  disability,  except  that  in  raising  the 
arm  from  the  side  the  superior  angle  impinges  upon  the  vertebral  column. 
This  limitation  of  movement  is  specially  marked  when  the  accessory 
ossicle  is  present. 

TREATMENT. — Little  benefit  seems  to  be  obtained  by  division  of 
the  contracted  muscles,  as  their  opponents  are  atrophic ;  but  when  the 
superior  angle  comes  into  contact  with  the  spine  and  limits  elevation  of 
the  arm,  this  process  may  be  sawn  off  with  advantage.  When  an  accessory 
ossicle  is  present  it  should  be  removed. 


CHAPTER    XV 
FLAT  FOOT 

FLAT  foot  is  essentially  an  affection  of  adolescence  ;  it  may,  however,  occur 
in  comparatively  young  children,  and  it  is  often  met  with  after  growth  has 
ceased.  It  is  sometimes  spoken  of  as  '  spurious  valgus,'  but  in  reality 
it  has  nothing  in  common  with  true  valgus,  as  it  IB  primarily  due  to  the 
giving  way  of  the  arch  of  the  foot. 

CAUSES. — The  affection  may  develop  either  rapidly  or  gradually. 
Acute  flat  foot  is  generally  the  result  of  some  inflammatory  condition 
affecting  the  structures  in  the  sole,  more  particularly  the  calcaneo-scaphoid 
ligaments  ;  it  is  common  as  a  form  of  gonorrhceal  rheumatism,  after 
acute  or  chronic  rheumatism  itself,  and  after  any  inflammatory  conditions 
about  the  foot  which  soften  the  ligaments.  The  acute  form  also  occurs  in 
conjunction  with  such  injuries  about  the  ankle  joint  as  Pott's  fracture  and 
fracture  of  the  astragalus  or  os  calcis.  These  cases  are  sometimes  called 
'  traumatic  flat  foot.' 

In  most  cases,  however,  flat  foot  develops  slowly,  and  is  most  marked 
in  weakly  subjects  and  in  those  whose  occupations  entail  prolonged 
standing,  such  as  barmaids  or  shop-assistants.  In  this  form  the  essential 
factor  at  work  is  a  gradual  weakening  of  the  muscles  which  should 
support  the  tarsal  bones.  As  a  result  of  this  failure  of  muscular  power — 
which  may  be  due  either  to  undue  weakness  of  the  muscles  or  to  unduly 
heavy  strains  being  put  upon  normal  muscles — excessive  strain  is  thrown 
upon  the  supporting  ligaments  of  the  tarsus  with  the  result  that  they 
become  stretched  and  allow  the  arch  of  the  foot  to  become  flattened. 
The  chronic  form  is  also  met  with  in  association  with  rickets,  particularly 
genu  valgum,  in  which  the  weight  of  the  body  is  thrown  more  upon  the 
inner  border  of  the  foot  than  upon  the  sole.  Any  condition  which  leads 
to  eversion  of  the  foot  throws  the  body  weight  upon  its  inner  border  and 
favours  the  production  of  this  deformity.  The  condition  seems  to  be 
more  common  in  males  than  in  females. 

PATHOLOGICAL  CHANGES.— As  the  result  of  the  yielding  of 
the  arch  of  the  foot,  the  head  of  the  astragalus  becomes  partially  dislocated 

299 


300  DEFORMITIES 

inwards  and  downwards  from  the  scaphoid,  and  in  bad  cases  it  may  only  arti- 
culate with  the  latter  at  the  extreme  outer  part  of  the  head ;  in  consequence 
the  cartilage  disappears  from  the  portion  of  the  bone  that  is  thus  exposed, 
and  the  head  forms  a  marked  prominence  beneath  the  skin  on  the  inner 
border  of  the  foot.  The  arch  of  the  foot  diminishes,  until  finally  the  sole  is 
applied  flat  to  the  ground.  In  well-marked  cases  the  anterior  part  of  the 
foot  becomes  abducted,  and  in  very  severe  ones  the  inner  border  of  the 
foot  may  be  actually  convex  and  the  outer  concave,  so  that  the  patient 
walks  more  on  the  inner  side  of  the  foot  than  on  the  outer,  although  not 
to  the  same  degree  as  in  cases  of  true  valgus. 

In  very  severe  cases  the  peronei  tendons  may  be  dislocated  from 
their  groove  and  lie  upon  or  anterior  to  the  external  malleolus.  In 
cases  of  long  standing,  marked  changes  also  occur  in  the  bones ;  the 
uncovered  portion  of  the  head  of  the  astragalus  becomes  enlarged,  so 
that  it  cannot  be  replaced  in  position.  Sometimes  actual  bony  anchylosis 
may  take  place.  There  may  be  effusion  into  the  sheaths  of  the  tendons 
behind  the  malleoli, 

SYMPTOMS. — As  flat  foot  develops,  pain  is  always  present 
although  it  varies  in  situation  and  degree.  In  the  acute  form  of  the  disease, 
the  pain  is  usually  so  severe  that  the  patient  is  unable  to  walk,  and  it  is 
chiefly  felt  in  the  sole  beneath  the  head  of  the  astragalus,  where  there  is 
also  marked  tenderness  on  pressure.  This  is  due  to  the  stretching  of  the 
ligaments  about  the  mid-tarsal  joint.  Pain  in  the  calf  from  stretching 
of  the  muscles  is  often  an  early  symptom  in  the  chronic  cases.  In  more 
advanced  cases  pain  is  also  experienced  along  the  outer  side  of  the  meta- 
tarsus and  about  the  external  malleolus.  The  pain  in  the  latter  situation 
is  often  due  to  actual  pressure  of  the  os  calcis  against  the  tip  of  the 
fibula. 

The  affection  is  generally  bilateral,  but  may  be  unilateral  only ;  it  is 
not  at  all  uncommon  for  patients  to  complain  of  pain  on  one  side  only. 
Many  persons  with  an  absolutely  flat  foot  suffer  from  no  symptoms 
whatever,  while  others  have  very  severe  symptoms  when  to  all  appear- 
ance the  arch  is  well  developed. 

TREATMENT. — For  the  purposes  of  treatment  flat  foot  may  be 
divided  into  five  stages. 

(1)  A  patient  begins,  comparatively  suddenly,  to  complain  of  pain  on 
standing,  referred  to  the  centre  of  the  sole.     On  examination  there  is 
tenderness  on  upward  pressure  in  the  sole,  and  some  flattening  of  the 
arch  of  the  instep.     This  is  the  '  acute  flat  foot '  usually  associated  with 
an  inflammatory  condition  of  the  ligaments  supporting  the   head  of 
the  astragalus  and  in  it  there  is  no  difficulty  in  bringing  the  foot  into 
position  and  restoring  the  arch ;  no  bony  deformity  has  yet  taken  place, 
nor  are  there  any  material  changes  in  the  ligaments. 

(2)  Chronic  cases  characterised  by  slight  pain,  in  which  the  arch 
can  be  restored  readily  by  manipulation. 


FLAT  FOOT  301 

(3)  Chronic  cases  in  which  there  is  considerable  deformity,  and  in 
which  the  arch  can  be  restored  only  with  difficulty. 

(4)  Bad  cases,   with   marked   deformity  which  cannot    be    reduced 
without  employing  considerable  force. 

(5)  The  most  severe  cases  of  all,  accompanied  by  bony  deformity 
or  anchlyosis,  in  which  reduction  is  impossible  even  after  using  great 
force. 

Acute  Flat  Foot.— The  treatment  must  be  directed  first  to  the 
arrest  of  the  inflammatory  condition  which  is  the  primary  cause  of  the 
affection  ;  the  arch  of  the  instep  must  also  be  supported  until  the  parts 
have  had  time  to  become  consolidated.  The  main  essential  is  rest ;  the 
patient  must  be  prohibited  from  standing  or  bearing  weight  upon  the 
foot.  Another  essential  is  to  arrest  the  inflammatory  condition  causing 
the  trouble.  The  means  at  our  command  for  this  purpose  are  numerous, 
and  the  choice  of  the  particular  form  will  depend  to  a  large  extent  upon 
the  cause  of  the  affection. 

In  gonorrhoeal  cases  the  treatment  must  be  directed  to  the  general 
condition  as  well  as  to  the  local  disease.  This  will  involve  the  use  of 
the  methods  appropriate  for  the  treatment  of  gonorrhoeal  diseases  of 
joints  and  ligaments,  which  are  described  in  detail  in  Vol.  III.  In  all 
cases  the  patient  should  be  confined  to  bed,  and  should  lie  with  the 
knee  bent  and  the  leg  resting  upon  the  outer  side  of  the  foot — a  position 
somewhat  resembling  that  of  the  tailor  at  work.  The  general  treatment 
most  suitable  for  the  condition  is  the  internal  administration  of 
quinine  and  iron,  whilst  means  should  be  employed  to  arrest  the 
gonorrhoeal  discharge  (see  Vol.  V.).  Vaccine  treatment  seems  to  be  of 
value  in  some  of  these  cases  (see  Appendix). 

It  is  essential  to  remember  the  great  tendency  to  the  occurrence  of 
anchlyosis  after  gonorrhoeal  arthritis.  Whilst  rest  is  essential  in  the 
earlier  stages,  fixation  apparatus,  such  as  plaster  of  Paris,  must  be 
employed  with  caution  and  for  a  short  time  only.  As  soon  as  the  arch 
of  the  instep  is  sufficiently  maintained  by  making  the  patient  lie  in  bed 
with  the  knee  flexed  and  the  weight  of  the  leg  bearing  upon  the  outer 
border  of  the  foot,  it  is  better  to  discard  all  fixation  apparatus,  and  to 
employ  massage  and  movements.  Adhesions  in  or  about  the  tarsal 
joints  must  be  broken  down  as  a  preliminary  measure. 

In  the  ordinary  rheumatic  cases,  salicylates  should  be  administered  ; 
hot  fomentations  are  of  value  if  the  pain  be  acute.  The  patient  should 
be  confined  to  bed,  with  the  knee  bent  and  the  foot  resting  upon  its  outer 
side  in  tailor-fashion  for  the  first  few  days  ;  this  position  alone  will  almost 
entirely  restore  the  arch  of  the  instep  in  these  cases. 

Fixation. — In  all  cases  of  acute  flat  foot,  except  those  due  to 
gonorrhoea,  it  is  well,  when  the  pain  begins  to  subside,  to  put  the  foot 
up  in  plaster  of  Paris  with  the  deformity  rather  over-corrected — viz.  with 
the  arch  of  the  instep  somewhat  exaggerated.  The  foot  should  be 


302 


DEFORMITIES 


kept  in  the  plaster  for  about  three  weeks,  or  at  any  rate  until  the  acute 
inflammatory  condition  has  subsided ;  then  massage,  douching,  and 
active  exercises  should  be  ordered,  so  as  to  strengthen  the  muscles  of  the 
foot. 

Exercises. — When  the  patient  raises  himself  upon  the  toes,  the  short 
muscles  of  the  foot  are  brought  into  action,  and  the  arch  of  the  foot  is 
increased ;  exercises  like  this  are  of  great  value.  The  patient  should 
stand  with  the  feet  together,  and  the  toes  pointing  directly  forward,  and 
should  then  raise  himself  gently  and  slowly  upon  tiptoe,  bending  the  knees 


FIG.  91. — WHITMAN'S  BRACE.    Making  a  cast  of  the  foot.    The  foot  is  laid  upon 
its  outer  border  upon  a  piece  of  lint  soaked  in  plaster  of  Paris. 

slightly  at  the  same  time.  This  exercise  repeated  for  a  certain  number 
of  times — at  first  from  ten  to  twenty — twice  daily,  and  later  on  for  five 
or  ten  minutes  at  a  tune  two  or  three  times  a  day,  will  do  much  to 
restore  the  arch  of  the  foot.  Another  exercise  of  considerable 
value  is  the  following.  After  the  patient  has  raised  himself  upon  tiptoe 
in  the  manner  just  mentioned,  the  knees  are  separated  while  the  feet 
remain  in  their  original  position,  so  that  the  lower  extremities  form  a 
letter  O  ;  in  other  words,  a  sort  of  artificial  genu  varum  is  formed. 
This  throws  the  weight  of  the  body  upon  the  outer  border  of  each  foot, 
and  so  tends  to  increase  the  arch  of  the  instep.  A  third  exercise,  somewhat 
similar  to  the  above,  consists  in  standing  upon  the  outer  border  of  the 
foot  with  the  feet  together,  the  soles  being  directed  inwards  towards  one 


JJO 


FLAT  FOOT 


303 


another.  These  exercises  should  not  be  carried  to  the  extent  of  tiring  the 
patient.  They  should  be  very  light  at  first  and  increased  gradually  ; 
it  is  better  to  practise  them  several  times  a  day  for  a  short  time  than  to 
have  a  single  long  sitting.  For  a  week  or  two  after  the  plaster  casing 
has  been  left  off,  the  patient  should  be  content  with  these  exercises,  which 
should  be  combined  with  massage  and  rest,  with  the  limb  in  the  tailor- 
position  ;  no  attempts  should  be  made  at  walking.  As  soon,  however, 
as  he  is  allowed  to  get  about,  there  is  no  better  form  of  exercise  for  the 
foot  muscles  than  bicycling,  which  may  be  indulged  in  freely. 

Whitman's  Spring.— When  the  tenderness  in  the  sole  has  almost 
disappeared  and  no  adhesions  in  the  tarsal  joints  remain,  the  patient 
may  be  allowed  to  walk  with  a  suitable  support  in  the  boot.  The  best 


FIG.  92. — WHITMAN'S  BRACE.    The  lint  has  been  folded  around  the  foot 
and  its  edge  turned  down. 

form  of  this  is  Whitman's  spring  or  '  brace,'  the  so-called  '  artificial 
instep  '  (see  Fig.  95).  The  apparatus  consists  of  a  support  modelled  upon 
a  plaster  cast  of  the  foot  taken  whilst  the  arch  of  the  instep  is  held  in  the 
fully  corrected  position.  It  fits  the  arch  of  the  foot  accurately,  extending 
forwards  almost  to  the  balls  of  the  toes,  outwards  round  the  outer  border 
of  the  foot,  and  backwards  to  just  in  front  of  the  tuberosity  of  the  os 
calcis.  On  the  inner  side  it  is  enlarged  upwards  and  extends  well  on  to 
the  inner  side  of  the  foot.  With  a  properly  made  support,  the  weight 
of  the  foot  is  not  borne  upon  the  apparatus  at  all  until  the  arch  begins  to 
sink  ;  the  foot  rests  upon  its  normal  bases  of  support,  namely,  the  under 
surfaces  of  the  heads  of  the  metatarsal  bones  and  the  tuberosities  of  the 
os  calcis,  and  the  spring  only  comes  into  action  when  the  arch  of  the  foot 


304 

sinks  unduly.     These  springs  should  be  accurately  fitted,  and  each  should 
be  specially  made  for  the  individual  who  has  to  wear  it. 

A  simple  method  of  taking  the  cast  is  as  follows.     The  patient  sits 


FIG.  93. — WHITMAN'S  BRACE.    The  trough-like  mould  formed  after  the  plaster 
has  set  and  the  foot  has  been  removed  from  it. 

upon  a  chair  with  his  foot  upon  a  second  chair  of  the  same  height,  and  the 
foot  lies  upon  its  outer  side  at  right-angles  to  the  leg  (as  shown  in  Fig  91). 
A  mackintosh  covered  by  a  newspaper  is  placed  upon  the  chair  under 


FIG.  94. — WHITMAN'S  BRACE.    The  mould  is  filled  with  a  mixture  of  tow  and 
plaster  of  Paris,  so  as  to  form  a  cast  of  the  foot. 

the  foot,  the  foot  is  well  oiled,  and  plaster  of  Paris  is  mixed  with 
water  to  form  a  thick  cream ;  a  piece  of  lint  is  steeped  in  the  plaster 
and  laid  upon  the  newspaper  underneath  the  foot  so  that  the  outer 


FLAT  FOOT 


305 


border  of  the  sole  rests  upon  it  along  a  line  about  an  inch  from  one  edge 
(see  Fig.  91).  The  lint  is  then  wrapped  round  the  foot,  covering  in  the 
heel  behind  and  extending  as  far  forward  as  the  cleft  between  the  toes ; 
it  should  reach  up  just  above  the  internal  malleolus,  but  should  not 
overlap  the  dorsal  sur- 
face to  any  extent. 
This  covering  is  allowed 
to  set,  and  when  the 
plaster  is  hard  there  is 
no  difficulty  in  remov- 
ing the  foot  from  it.  A 
fresh  lot  of  plaster  is 
now  made  and  some 
tow  is  mixed  in  with  it. 
The  mould  is  well  oiled, 
and  the  mixture  of 
plaster  and  tow  is  laid 
in  it  and  arranged  so 
that  it  fills  the  mould 
but  does  not  project 
beyond  it  in  any  direc- 
tion. When  the  plaster 
mixture  has  set,  the 
sides  of  the  mould  are 
forced  aside  and  the 
cast  is  removed  and 
marked  for  the  instru- 
ment -  maker.  This 
method  of  making  a 
cast  is  much  simpler 
than  that  described  by 
Whitman  and  is  equally 
serviceable  ;  an  excel- 
lent cast  can  be  pro- 
duced by  it  without 
having  recourse  to 
skilled  assistance. 

The  brace  is  made 
of  thin  steel  1  and  should  extend  forwards  to  the  line  of  the  metatarso- 
phalangeal  joint  of  the  great  toe  and  backwards  to  the  centre  of  the 
heel ;  on  the  inner  side  of  the  foot  it  extends  upwards  to  half  an  inch 
below  the  internal  malleolus  and  on  the  outer  side  grasps  the  foot  just 
behind  the  prominence  formed  by  the  fifth  metatarsal.  It  should  be 

1  It  may  also  be  made  of  aluminium  or  phosphor-bronze ;   these  materials  do 
not  rust. 

i.  x 


FIG.  95. — WHITMAN'S  BRACE.  The  brace  moulded  upon  tho 
cast  and  viewed  from  the  outer,  plantar,  and  Inner  aspects 
respectively. 


306 


DEFORMITIES 


made  to  fit  the  cast  accurately  except  over  the  heel,  where  it  should  be 
slightly  flattened  so  as  to  make  it  steadier. 

A  badly  fitting  apparatus  extends  either  too  far  forwards  or  too  far 
backwards,  and  causes  so  much  pain  that  the  patient  is  unable  to  wear 
it ;  when  it  fits  properly,  however,  the  patient  soon  becomes  accustomed 
to  it  and  cannot  do  without  it.  Sometimes  it  causes  a  little  discomfort 
at  first,  and,  until  the  patient  has  become  accustomed  to  it,  it  should 
only  be  worn  for  short  periods  at  a  time,  the  length  of  time  being  gradually 
increased  as  tolerance  is  established.  It  should  be  worn  in  the  house- 
shoes  as  well  as  in  the  boots,  as  long  as  there  is  any  tendency  to  sinking 
in  the  arch  of  the  foot. 


FIG.  96. — BOOTS  FOR  USE  IN  FLAT  FOOT.  A  shows  the  obliquity  of  the  heel 
from  the  back.  B  shews  both  the  obliquity  of  the  heel  and  the  filing  up  of  the 
waist  of  the  boot  by  carrying  the  heel  forward  beneath  the  arch  of  the  instep  to  join 
the  sole.  This  is  well  seen  in  C,  which  is  a  view  of  the  boot  from  its  inner  side. 
(Modified  from  Hoffa.) 


Boots. — The  sole  of  the  boot  should  also  be  strengthened  beneath 
the  instep  by  continuing  the  heel  forwards  on  the  inner  side  until  it 
meets  the  front  part  of  the  sole  ;  it  is  also  of  advantage  to  make  the 
sole  and  heel  thicker  on  the  inner  side  than  on  the  outer,  so  as  to  raise 
the  inner  border  of  the  foot  (see  Fig.  96).  The  patient  should  be 
cautioned  not  to  turn  the  toes  out  whilst  walking  ;  they  should  be  directed 
straight  forwards,  and  the  knees  should  be  rotated  slightly  inwards. 
It  is  also  weU  to  direct  the  patient  to  raise  himself  on  tip-toe  from  time 
to  time  when  walking,  and  to  walk  rather  upon  the  toes  than  flat  upon 
the  sole.  He  should  not  walk  too  far  at  first,  and  should  never  be 
allowed  to  continue  walking  until  the  foot  feels  tired ;  the  amount  of 
exercise  should  be  prolonged  gradually. 

When  the  condition  is  chronic,  when  there  is  but  little 
pain,  and  when  the  arch  can  be  restored  readily  to  its  normal  condition,  it  is 


FLAT  FOOT  307 

not  necessary  to  employ  absolute  rest  in  bed  with  fixation  in  plaster  of 
Paris.  Any  adhesions  in  the  tarsal  joints  that  may  exist  should  be 
broken  down  under  anaesthesia  by  grasping  the  foot  with  the  two  hands 
and  moving  the  front  half  upon  the  back  freely  and  in  all  directions.  Then 
the  exercises  above  described  should  be  carried  out,  friction,  massage, 
and  douching  should  be  employed,  and  gentle  exercise  encouraged 
while  the  patient  is  wearing  a  Whitman's  spring.  In  these  cases  treat- 
ment must  be  continued  for  a  long  time ;  indeed,  many  patients  must 
use  a  spring  for  the  rest  of  their  lives  both  in  their  walking  boots  and 
their  house-shoes.  Any  co-existing  causes  of  flat  foot  must  be  remedied 
if  possible.  Should  the  patient  be  weak  or  anaemic,  iron  may  be  adminis- 
tered, and  any  deformity,  such  as  genu  valgum,  which  may  be  the  cause 
of  the  affection,  must  receive  appropriate  treatment ;  it  is  futile  to  treat 
a  case  of  flat  foot  depending  upon  genu 
valgum  without  removing  the  primary  cause. 
When  there  is  marked  oblitera- 
tion of  the  arch  accompanied  by 
considerable  eversion  of  the  foot, 
and  when  there  is  also  difficulty  in  restoring 
the  arch  by  manipulation,  it  may  be  necessary 
to  have  recourse  to  some  form  of  elastic 
traction  in  order  to  support  the  instep.  The 
same  method  may  also  be  called  for  when 
Whitman's  spring  gives  rise  to  much  pain. 
A  good  apparatus  for  this  purpose  is  Golding 
Bird's  modification  of  Barwell's  spring, 
which  is  essentially  an  artificial  tibialis 
anticus  muscle  (see  Fig.  97).  It  consists  of 
a  sling  of  webbing  encircling  the  ankle  and  applied, 
passing  down  across  the  outer  border  of  the 

foot  and  beneath  the  arch  of  the  instep,  terminating  on  the  inner  side 
just  above  the  head  of  the  astragalus  in  a  hook  to  which  is  fastened  one 
end  of  a  stout  india-rubber  door-spring ;  the  other  end  of  this  is  attached 
to  an  outside  leg-iron  which  is  hinged  into  the  heel  of  the  boot  below, 
and  fastened  to  a  band  encircling  the  leg  just  opposite  the  tubercle  of 
the  tibia.  The  apparatus  is  applied  as  follows.  The  sling  is  arranged 
around  the  ankle  and  beneath  the  instep  outside  the  stocking,  and 
the  boot  is  put  on  and  the  leg-iron  adjusted  to  the  heel  whilst  the 
free  end  is  pulled  upon  firmly.  The  elastic  band  is  then  fastened  in 
position,  and  the  upper  end  of  the  leg-iron  is  adjusted.  A  slit  must 
be  made  in  the  upper  leather  of  the  boot  through  which  the  free  end  of 
the  sling  is  passed  before  the  spring  is  attached  to  it.  This  apparatus 
supports  the  arch  of  the  foot  well,  and  without  pain.  At  the  same 
time  it  is  cumbrous  and  expensive,  and  we  do  not  advise  its  use  when 
the  metal  spring  will  answer  its  purpose.  It  is,  however,  a  good  method 

X  2 


303 


DEFORMITIES 


when  there  is  much  spasm  and  pain.  The  accessory  methods  of 
treatment  are  similar  to  those  already  described  for  the  milder 
cases. 

In  the  still  more  advanced  cases,  when  it  is  impossible  to 
restore  the  arch  of  the  instep  by  manipulation,  and  when  the  deformity 
is  associated  with  shortening  of  the  ligamentous  structures  on  the 
outer  side  of  the  foot,  as  well  as  spasm  of  the  peroneal  muscles  in  some 
cases,  the  tense  structures  should  be  stretched  fully.  The  patient  should 

be  placed  under   an    anaesthetic,   and    the 

I  foot  manipulated  in  all  directions,  so  as  to 

break  down  any  adhesions  that  may  be 
present.  The  inner  side  of  the  foot  should 
then  be  fixed  by  pressing  it  firmly  against 
the  surgeon's  knee,  whilst  the  front  of  the 
foot  is  grasped  with  one  hand  and  the  heel 
with  the  other  and  the  abduction  of  the 
front  half  of  the  foot  is  forcibly  over- 
corrected.  This  often  calls  for  the  exercise 
of  considerable  force.  If  mere  manipulation 
of  this  kind  does  not  enable  the  surgeon  to 
restore  the  arch  of  the  instep  satisfactorily, 
still  greater  force  must  be  employed  to 
stretch  or  break  through  the  resisting  struc- 
tures by  means  of  a  Thomas's  wrench  (see 
Fig.  116),  which  is  adjusted  to  the  anterior 
part  of  the  foot,  and  by  means  of  which  the 
parts  may  be  brought  forcibly  into  position. 
After  this  has  been  done,  the  foot  should 
be  put  up  in  plaster  of  Paris,  with  the  de- 
formity over-corrected,  for  about  six  weeks. 
It  is  well  to  renew  the  casing  every  ten  days, 
as  it  is  apt  to  get  loose,  and  in  these  intervals 
massage  and  passive  movements  in  all  direc- 
tions should  be  practised.  When  the  splint 
is  left  off,  tiptoe  exercises  (see  p.  302)  should 
be  combined  with  douching  and  massage. 

The  arch  of  the  instep  should  be  supported  in  the  first  place  by  Golding 
Bird's  apparatus,  for  which  Whitman's  spring  may  be  substituted 
when  the  parts  become  more  consolidated.  The  general  treatment  is 
similar  to  that  already  described. 

In  the  worst  cases,  in  which  even  forcible  manipulation  by  a 
Thomas's  wrench  fails  to  bring  the  parts  into  position,  the  treatment 
is  most  difficult.  The  bony  deformity  is  extreme,  and  the  pain  and 
disability  from  which  the  patient  suffers  may  be  so  great  that  some  form 
of  operative  procedure  becomes  necessary.  Some  surgeons  advocate 


FIG.  98. — GOLDING  BIRD'S  AP- 
PARATUS FOR  FLAT  FOOT.  The 
sketch  shows  how  the  sling  is  brought 
through  a  slit  in  the  boot  and  fas- 
tened to  an  external  iron. 


FLAT  FOOT  309 

excision  of  the  astragalo-scaphoid  articulation,  some  remove  a  wedge 
from  the  neck  of  the  astragalus,  whilst  others  excise  a  wedge-shaped 
portion  of  the  tarsus,  without  regard  to  the  structures  removed.  The 
operations  most  generally  useful  are  the  removal  of  the  head  of  the 
astragalus,  or  a  partial  excision  of  the  astragalo-scaphoid  joint  as  described 
by  Ogston. 

Excision  of  the  Head  of  the  Astragalus. — This  is  perhaps  the  best 
operation  on  the  whole.  It  can  be  done  readily  by  an  incision  similar  to  that 
required  for  Ogston's  operation  (vide  infra),  and  is  not  necessarily  followed 
by  anchylosis.  The  disadvantage  of  the  operation  is  that  there  is  a 
tendency  for  depression  of  the  arch  to  recur  as  a  result  of  the  absence  of 
anchylosis,  and  therefore  a  Whitman's  spring  must  be  worn  constantly 
after  the  operation. 

Ogston's  Operation  aims  at  producing  bony  anchylosis  between  the 
scaphoid  and  the  astragalus,  after  the  foot  has  been  got  into  position. 
It  is  performed  as  follows.  Under  full  anaesthesia  any  adhesions  present 
are  broken  down  by  free  and  forcible  movements  in  all  directions.  Then 
an  attempt  is  made  to  rectify  the  position  of  the  foot  as  far  as  possible 
by  means  of  the  hand,  aided,  if  necessary,  by  a  wrench.  An 
incision  is  then  made  along  the  inner  aspect  of  the  foot,  from  just  below 
the  anterior  margin  of  the  internal  malleolus,  downwards  and  forwards 
to  a  point  beyond  the  tubercle  of  the  scaphoid.  The  tendon  of  the  tibialis 
anticus  must  be  avoided  in  deepening  the  incision  ;  it  can  be  drawn  aside 
with  a  retractor.  The  astragalo-scaphoid  joint  is  then  opened,  and 
the  whole  of  the  articular  cartilage  covering  the  head  of  the  astragalus 
and  the  corresponding  part  of  the  scaphoid,  is  stripped  off  with  a  peri- 
osteum detacher  or  a  chisel.  If  the  altered  shape  and  increased  size  of  the 
astragalus  still  renders  it  impossible  to  bring  the  foot  into  position, 
enough  of  that  bone  may  be  removed  with  a  chisel  to  enable  this  to  be 
effected.  The  foot  is  then  forcibly  inverted  and  adducted,  and  the  arch 
of  the  instep  is  raised  by  depressing  the  metatarsal  bones ;  when  the 
position  appears  to  be  satisfactory,  a  hole  is  drilled  through  the  scaphoid 
from  before  backwards  and  outwards  and  continued  on  into  the  head  of 
the  astragalus.  Through  this  is  inserted  an  ivory  peg,  a  screw,  or  a  nail, 
which  serves  to  keep  the  bones  steady  in  their  new  position ;  whichever 
of  these  be  used  to  fix  the  bones,  its  inner  end  should  lie  flush  with  the 
scaphoid.  The  wound  is  closed  without  a  drainage-tube,  and  outside  the 
dressings  is  applied  a  plaster  of  Paris  casing,  extending  from  the  base  of 
the  toes  up  to  about  the  centre  of  the  calf ;  the  foot  is  held  in  its  new 
position  while  the  plaster  sets. 

The  casing  need  not  be  disturbed  for  about  six  weeks  if  no  pain  be 
complained  of.  Bony  union  should  then  be  fairly  complete,  and  the 
patient  may  be  allowed  to  walk.  Should  there  be  any  pain,  however, 
or  should  the  casing  become  loose,  it  must  be  removed,  the  wound 
re-dressed,  and  a  fresh  casing  applied.  After  the  casing  has  been  left  off, 


3io  DEFORMITIES 

the  arch  of  the  instep  should  be  supported  by  a  Whitman's  spring,  but 
this  can  generally  be  discarded  in  about  two  months.  The  boots  should 
have  a  high  arch  to  the  instep,  and  the  latter  should  be  supported  still 
further  by  extending  the  heel  forwards  (see  p.  306). 

The  objections  urged  against  this  operation  are  that  in  bad  cases  it 
is  not  always  easy  to  bring  the  foot  into  proper  position  after  it,  and  that 
the  transverse  tarsal  joint  loses  its  mobility,  and  therefore  the  foot  is 
deprived  of  some  of  its  normal  elasticity.  Nevertheless,  it  effects  a  great 
improvement  in  the  condition  of  the  patient,  and  it  gives  better  results 
than  any  that  can  be  obtained  by  mechanical  means  in  cases  which  have 
reached  this  degree  of  severity. 

Removal  of  a  Wedge-shaped  Portion  of  the  Tarsus. — In  cases  of  the 
most  severe  type  of  all,  the  only  chance  of  a  successful  result  is  by  the 
removal  of  a  wedge-shaped  piece  of  the  tarsus,  the  base  of  the  wedge 
being  on  the  inner  side  of  the  foot,  and  the  apex  at  the  outer.  This 
operation  is  performed  in  a  similar  manner  to  that  described  for  bad 
cases  of  talipes  varus  (see  p.  358),  except  that  in  the  latter  case  the  base  of 
the  wedge  is  on  the  outer  side  of  the  foot,  and  we  may  therefore  refer  to  the 
description  there  given.  As  a  result  of  this  operation  the  bones  become 
anchylosed,  but  the  patient  is  really  much  more  comfortable  if  the  foot 
has  been  brought  into  accurate  position,  notwithstanding  anchylosis. 
Other  operations,  such  as  Stokes's  excision  of  a  wedge  from  the  neck  of 
the  astragalus,  excision  of  the  astragalus,  or  of  various  tarsal  bones,  have 
nothing  to  recommend  them  in  preference  to  the  procedures  already 
described. 

WEAK    ANKLES. 

In  this  condition,  which  is  common  in  young  children,  the  child 
habitually  walks  on  one  side  of  the  foot  producing  an  apparent  valgus  or 
varus.  The  deformity  can  be  readily  distinguished  from  a  true  talipes 
by  the  ease  with  which  it  can  be  corrected.  The  child  wears  the  soles 
of  his  boots  irregularly,  and  the  uneven  basis  of  support  thus  produced 
tends  to  confirm  the  habit  and  aggravate  the  condition.  The  essential 
trouble  in  these  cases  is  muscular  weakness. 

TREATMENT.— This  must  be  directed  in  the  first  place  to  the 
general  muscular  system,  and  in  the  second  to  any  group  or  groups  of 
muscles  that  are  specially  at  fault.  The  patient  should  be  put  in  healthy 
surroundings  and  should  have  simple  nourishing  food  and  active  outdoor 
exercise,  which  should  never  be  pushed  to  the  point  of  fatigue.  Little 
children  who  are  supposed  to  be  delicate  are  often  loaded  with  excessive 
garments  under  the  mistaken  impression  that  they  need  special  warmth  ; 
clothing  should  of  course  be  warm,  but  it  must  be  light  so  as  not  to  impede 
the  patient's  activity.  In  the  intervals  between  the  periods  of  activity 
rest  must  be  insisted  upon.  In  many  cases  attention  to  these  points  is 


INTOEING 

all  that  is  required,  but  this  general  treatment  may  be  supplemented  by 
a  system  of  exercises  designed  to  improve  the  general  muscular  power. 
A  list  of  such  exercises  will  be  found 
under  Scoliosis  (p.  423).     Massage  of 
the  legs  is  also  of  value. 

In  addition,  the  child  should  wear 
strong  boots  which  are  frequently 
mended  and  prevented  from  irregular 
wear  by  metal  plates.  In  the  country 
the  child  may  wear  sandals  or  go 
barefoot. 

INTOEING. 

This  condition  is  often  difficult  to 
correct,  the  child  walking  with  the 
toes  pointing  inwards,  so  that  when 
he  attempts  to  run  he  trips  over  his 
own  feet  and  falls. 

TREATMENT.— General  treat- 
ment on  the  lines  mentioned  above  is 
of  value,  but  in  addition  it  is  usually 
necessary  to  provide  some  means  of 
rotating  the  feet  outwards,  and  for 
this  purpose  the  apparatus  shown  in 
Fig.  99  is  useful.  A  band  of  elastic 
webbing  is  fastened  to  the  outer  side 
of  the  toe  of  the  boot  and  then  wound 
round  the  leg,  passing  behind  the  knee 

and  over  the  front  of  the  thigh,  to  end  at  a  point  in  the  middle  of  the 
back,  where  it  is  fixed  to  a  belt  or  to  the  child's  braces ;  this  is 
kept  tight  and  exerts  a  steady  external  pull  sufficient  to  correct  the 
deformity. 


Fig-  99- — WHITMAN'S  APPARATUS  FOR  In 
TOEING. — The  photograph  shows  the  appa 
ratus  as  constructed  by  the  parent  of  an 
out-patient.  Bands  of  elastic  are  fastened  to 
the  outer  parts  of  the  boots  and  then  wound 
spirally  around  the  limbs,  being  attached 
above  to  the  back  of  the  girdle. 


CHAPTER    XVI. 
CLUB-FOOT. 

BY  the  term  Club-foot  or  Talipes  is  understood  a  permanent  deformity 
of  such  a  nature  that  the  foot  is  inclined  at  an  angle  to  the  leg,  so  that  the 
sole  no  longer  rests  upon  the  ground  in  the  normal  position  when  the 
patient  bears  his  weight  upon  it.  The  directions  in  which  the  foot  may  be 
displaced  are  various,  and  the  displacements  may  be  either  simple  or 
complex.  Of  the  simple  forms  of  club-foot  we  may  enumerate  Talipes 
Equinus,  in  which  the  heel  is  drawn  up  and  the  toes  are  pointed,  the 
patient  walking  upon  the  extremities  of  the  metatarsal  bones ;  Talipes 
Calcaneus,  in  which  the  reverse  condition  exists,  the  front  part  of  the  foot 
being  drawn  up  and  the  patient  walking  upon  the  heel ;  Talipes  Varus,  in 
which  the  foot  is  inverted,  and  the  patient  walks  upon  its  outer  border  ; 
and  Talipes  Valgus,  in  which  the  foot  is  everted,  and  the  patient  walks 
upon  the  inner  border.  In  the  great  majority  of  cases,  however,  the 
deformity  is  a  mixed  one,  the  most  frequent  being  Talipes  Equino-varus, 
which  is  a  combination  of  talipes  equinus  with  varus.  Talipes  Equino- 
valgus,  Talipes  Calcaneo-valgus,  and  various  other  less  important  forms 
are  also  met  with ;  there  is  also  the  affection  known  as  Pes  Cavus,  or 
hollow  club-foot,  in  which  the  arch  of  the  instep  is  exaggerated  and  the 
plantar  fascia  is  shortened.  The  cases  of  club-foot  may  be  divided  into 
two  great  classes,  namely,  the  congenital  form,  in  which  the  condition 
is  present  at  birth,  and  the  acquired  one,  in  which  the  affection  develops 
at  a  later  period. 

CAUSES  AND  PATHOLOGICAL  CHANGES.— Congenital 
talipes  is  probably  due  primarily  to  some  arrest  of  development  in  the  foetus 
more  particularly  to  failure  of  the  foot  to  rotate  from  its  fcetal  to  its  post- 
natal position.  During  early  intra-uterine  life,  the  feet  lie  in  a  position 
closely  resembling  talipes  equino-varus,  but  shortly  before  birth  the  lower 
extremity  becomes  rotated  in  such  a  manner  that  the  foot  assumes  its 
normal  position ;  if  from  any  cause  this  rotation  does  not  take  place, 

312 


CLUB-FOOT  313 

congenital  talipes  equino-varus  is  the  result.  Congenital  club-foot  may 
also  be  associated  with  imperfect  development  of  the  bones  of  the  leg  ; 
thus  absence  of  the  fibula  may  give  rise  to  a  talipes  valgus,  and  absence  of 
the  tibia  may  give  rise  to  a  talipes  varus.  The  latter  condition  is  very 
rare. 

In  most  cases  of  congenital  talipes  there  is  imperfect  development  of 
some  of  the  bones  of  the  foot.  This  is  most  marked  in  the  astragalus  and 
takes  the  form  of  an  actual  alteration  in  the  axes  of  the  bones ;  at  first, 
at  any  rate,  the  muscles  are  not  altered  in  length.  In  addition  to  the 
alteration  in  the  shape  of  the  bones,  shortening  of  some  of  the  ligaments 
occurs  rapidly,  and  if  the  deformity  be  uncorrected,  the  shortening  of  the 
ligaments  becomes  still  more  marked  as  time  goes  on,  whilst  the  muscles, 
accommodating  themselves  to  the  altered  position  of  the  limb,  may  also 
become  permanently  altered  in  length.  It  is  of  great  importance  in  the 
treatment  to  remember  that,  while  we  have  only  to  do  with  a  faulty  shape 
and  position  of  the  bones  in  the  early  stages,  in  later  life  there  is,  in  addi- 
tion, a  permanent  shortening  of  the  muscles,  fasciae,  and  ligaments.  The 
bony  deformity  increases  and  becomes  permanent  and,  if  the  patient  be 
allowed  to  attain  adult  life  with  the  foot  in  its  faulty  position,  the  shape 
of  the  bones  and  the  position  of  their  articular  surfaces  are  so  com- 
pletely altered  that  some  radical  operation  is  required  to  rectify  the 
condition. 

Of  acquired  club-foot  there  are  numerous  causes.  The  most  frequent 
form  is  the  paralytic,  resulting  from  the  paralysis  of  certain  groups  of 
muscles,  generally  due  to  infantile  paralysis  ;  the  muscles  most  frequently 
affected  are  those  of  the  front  and  outer  aspects  of  the  leg.  As  a  sequel 
to  the  loss  of  power  in  the  muscles,  the  foot  assumes  a  faulty  position  by 
its  mere  weight.  Later  on,  the  unaffected  muscles  become  shortened, 
their  action  being  unbalanced  by  the  paralysed  ones,  and  the  condition 
present  is  then  one  of  permanent  contraction  of  the  active  muscles,  and 
over-stretching  and  degeneration  of  the  affected  ones.  As  the  case 
progresses,  the  structure  and  direction  of  the  articular  surfaces  of  the 
bones  become  altered  unless  steps  be  taken  to  keep  the  foot  in  proper 
position. 

Another  cause  of  the  paralytic  form  of  the  deformity  is  injury  to  a 
nerve  trunk,  such  as  a  gun-shot  or  other  wound,  or  a  fracture  involving 
the  nerve.  In  other  cases,  the  deformity  may  result  from  spastic  con- 
traction of  certain  muscles  due  to  various  causes,  such  as  affections  of  the 
central  nervous  system.  Talipes  may  also  be  one  of  the  manifestations 
of  hysteria.  Again,  the  deformity  may  be  caused  by  myositis  due  to  the 
presence  of  an  inflammatory  focus  in  the  affected  muscles  or  their  vicinity 
which  leads  to  their  contraction,  or  it  may  result  from  inflammation  in 
the  neighbourhood  of  tendons  giving  rise  to  adhesions  while  the  foot  is  in 
a  faulty  position.  Occasionally  also  club-foot  may  be  due  to  the  condi- 
tion known  as  'ischsemic  paralysis '  (see  Vol.  II.). 


314  DEFORMITIES 

There  are  also  many  other  less  frequent  causes  of  talipes.  For 
example,  it  may  result  from  the  contraction  of  cicatrices  after  wounds, 
ulcers  of  the  leg,  burns,  etc.,  or  as  the  result  of  joint  diseases  in  which 
proper  attention  has  not  been  paid  to  the  position  of  the  foot,  and  some- 
times also  it  may  occur  from  the  long-continued  assumption  of  a  faulty 
position  without  any  disease  in  the  ankle.  In  these  cases,  the  usual  de- 
formity seen  is  talipes  equinus,  which  is  due  to  the  natural  pointing  of  the 
toes,  aided  in  many  cases  by  the  weight  of  the  bed-clothes.  Again,  in 
cases  of  marked  ricketty  curvatures  of  the  lower  extremity,  there  is  often 
some  form  of  talipes  present,  particularly  valgus.  The  affection  may 
also  occur  as  the  result  of  osteitis  ;  acute  osteo-myelitis  affecting  only  one 
of  the  bones  of  the  leg  may  cause  the  destruction  of  the  epiphyseal  line 
in  the  affected  bone,  so  that  there  is  arrest  of  growth  in  it ;  the  result  is 
that  the  foot  will  be  displaced  as  the  other  bone  grows,  and  talipes  will 
ensue.  It  is  quite  common  as  a  result  of  fractures  about  the  ankle  joint 
when  reduction  has  not  been  satisfactory. 

TREATMENT.— General  Indications.— If  the  affection  be  of 
congenital  origin,  the  treatment  in  the  earlier  stages  need  not  be 
directed  so  much  against  contraction  of  the  muscles  as  against  the  altera- 
tions which  have  occurred  in  the  shape  of  the  bones,  and  its  aim  must 
be  to  rectify  the  altered  direction  of  these  whilst  they  are  still  soft. 
If,  however,  the  condition  remains  untreated  until  later  life,  a  satisfactory 
result  may  only  be  obtainable  by  an  operation  dealing  with  tendons  as 
well  as  the  bones.  In  the  acquired  variety,  on  the  other  hand,  the  pri- 
mary lesions  are  usually  situated  in  the  muscles  and  soft  parts,  and  the 
alteration  in  the  shape  and  structure  of  the  bones  only  occurs  when  the 
deformity  has  been  allowed  to  continue  for  a  considerable  time  ;  hence, 
in  the  early  stage  the  chief  attention  must  be  directed  to  the  muscles  and 
ligaments.  In  the  spastic  cases,  means  must  be  taken  to  relieve  the 
spasm,  while  at  the  same  time  division  of  some  of  the  tendons  may  be 
necessary.  When  the  club-foot  is  of  paralytic  origin,  the  chief  point  in  the 
treatment  is  to  restore  the  power  of  the  muscles  by  massage,  electricity, 
and  the  use  of  suitable  apparatus  to  prevent  over-stretching  of  the  weak 
muscles  and  undue  contraction  of  the  sound  ones.  Much  of  the  disability 
may  be  due  to  the  fact  that  certain  muscles  are  overstretched,  and  appro- 
priate splinting,  by  relaxing  their  tendons,  may  be  followed  by  extensive 
recovery  of  function.  By  means  of  tendon  transplantation  also,  healthy 
muscles  may  be  made  to  perform  the  functions  of  paralysed  ones, 
while  arthrodesis,  or  removal  of  the  articular  cartilage,  may  be  required 
to  transform  certain  flail-like  joints  in  which  all  the  muscles  concerned 
are  paralysed,  into  fixed  ones  (see  p.  341).  Occasionally  also  it  may  be 
possible  to  improve  matters  by  grafting  a  sound  nerve  into  the  paralysed 
one.  When  the  affection  is  caused  by  cicatrices,  these  must  be  removed 
or  divided. 

The  earlier  the  treatment  is  begun,  the  better  is  the  prospect  of  a  good 


CONGENITAL  CLUB-FOOT  315 

result,  for,  if  the  early  stages  be  neglected,  the  final  result  is  alteration 
in  the  bones  and  the  articular  surfaces,  and  shortening  of  ligaments 
and  tendons,  whatever  may  have  been  the  primary  lesion.  Simple 
division  of  the  tendons  or  ligaments,  manipulations,  and  the  use  of  appar- 
atus then  fail  to  restore  the  foot  to  its  proper  position,  and  more  severe 
measures  must  be  employed. 


GENERAL  POINTS  IN  THE  TREATMENT  OF 
CONGENITAL  CLUB-FOOT. 

These  cases  fall  into  three  distinct  groups,  (i)  Those  in  which 
the  deformity  can  be  rectified  by  manipulation  alone  ;  in  these  cases 
there  are  no  shortened  structures  to  impede  the  re-position  of  the  foot, 
and  the  deformity  in  the  bones  is  only  slight. 

(2)  Cases  of  long  standing  in  which  there  is  shortening  of  the  muscles 
and  ligaments,  resulting  from  the  long-continued  faulty  position  of  the 
limb  ;   when  these  contracted  structures  have  been  divided,  the  foot  can 
be  got  into  position  with  a  little  effort,  the  alterations  in  the  bones  not  yet 
being  advanced  enough  to  offer  any  great  impediment. 

(3)  The  third  group  consists  of  cases  of  very  long  standing  in  which 
the  obstacles  to  reduction  are  not  merely  tight  muscles,  ligaments,  and 
fasciae,  but  also  alterations  in  the  direction  and  extent  of  the  articular 
surfaces  which  have  become  so  pronounced  that  re-position  is  impossible 
without  operation.     These  alterations  in  the  bones  are  partly  changes 
in  their  shape  and  direction,   and  partly  alterations  in  the  articular 
cartilages.     When,  as  the  result  of  the  faulty  position  of  the  foot,  a 
portion  of  the  articular  cartilage  has  remained  for  a  long  time  out  of 
contact  with  the  articular  surface  of  the  corresponding  bone,  fibroid 
changes  occur  in  it  converting  it  into  nbro-cartilage ;    ultimately  the 
whole  of  the  uncovered  portion  of  the  articular  surface  becomes  denuded 
of  cartilage.     Thus,  the  opposed  surfaces  are  no  longer  covered  with 
articular  cartilage  even  when  the  bones  are  in  proper  position.     More- 
over, there  are  often  alterations  in  the  shape  of  the  bone  beneath,  so  that 
it  is  no  longer  possible  to  bring  the  two  joint  surfaces  into  proper  relation 
with  each  other  unless  some  alteration  is  made  in  their  shape.     In  severe 
cases  the  entire  limb  may  be  rotated,  and  it  will  be  necessary  to  correct 
this  before  locomotion  will  become  normal. 

It  is  very  important  to  remember  that  the  patient  must  not  be  re- 
garded as  cured  as  soon  as  the  foot  has  been  got  into  position,  or  even 
after  it  has  been  maintained  there  for  some  weeks.  If  treatment  be 
left  off  too  soon,  a  relapse  takes  place  almost  at  once,  and  the  subsequent 
condition  may  become  as  bad  as  or  even  worse  than  if  no  treatment  had 
been  employed.  Hence,  it  must  be  impressed  on  the  parents  that  the 


316 


DEFORMITIES 


treatment  should  be  continued  for  several  years  at  least  after  apparently 
complete  recovery. 

In  the  eases  in  which  it  is  possible  to  get  the  foot  into  position 
without  the  exercise  of  any  force,  the  treatment  will  consist  in  the 
methodical  employment  of  manipulations,  so  as  to  keep  the  parts 
stretched,  and  the  adoption  of  means  designed  to  strengthen  the  action 
of  any  muscles  that  may  be  deficient  in  power  ;  besides  this,  the  bony 
deformity  which  already  exists  must  be  corrected,  and  prevented  from 
recurring.  The  first  two  objects  are  attained  by  the  use  of  suitable 
manipulations  and  massage,  whilst  for  the  third  some  form  of  apparatus 
must  be  employed. 


FIG.  100. — METAL  TALIPES  SPLINT.  A  shows  the  splint  before  application.  B  illus- 
trates the  splint  applied  to  the  foot  while  still  in  its  faulty  position.  The  splint  is  easily 
made  to  fit  the  foot  by  bending  the  stout  copper  connecting  wire  a.  C  shows  the  faulty 
position  of  the  foot  rectified  by  bending  the  splint  back  into  the  position  shown  in  A , 
while  the  foot  is  firmly  fixed  to  it. 


When  congenital  club-foot  is  detected  early  enough  to  be  remediable 
by  the  hand,  the  position  of  the  foot  should  be  over-corrected  several 
times  a  day.  It  is  of  great  advantage  that  this  correction  should 
be  carried  out,  in  the  first  instance  at  any  rate,  by  the  medical  man 
himself ;  it  should  be  done  by  grasping  the  anterior  half  of  the  foot 
with  one  hand  and  gently,  firmly,  and  slowly  bringing  it  into  its  proper 
position,  whilst  the  posterior  half  is  fixed  by  the  other  hand.  It  is 
essential  that  these  manipulations  should  be  carried  out  without  using 
any  force,  as  spasm  of  the  muscles  is  at  once  set  up  if  it  be  done  roughly  ; 
this  interferes  with  the  proper  replacement,  and  soon  teaches  the  child 


CONGENITAL  CLUB-FOOT 


317 


to  resent  the  manipulations,  so  that  after  a  few  days  no  further  progress 
is  made.  The  foot  should  be,  so  to  speak,  rather  coaxed  than  forced 
into  its  proper  position  ;  after  the  foot  has  been  brought  into  position 
it  should  be  held  there  for  ten  minutes.  It  will  usually  be  found  that 
re-position  can  be  effected  readily,  and  the  child  does  not  object  to  the 
renewal  of  the  manipulations  on  subsequent  occasions,  and  in  the  course 
of  a  few  days  it  will  be  possible  to  over-correct  the  deformity  without 
exciting  spasm  of  the  muscles ;  this  should  be  aimed  at  in  all  cases. 
The  nurse  should  rub  the  leg  gently  and  knead  the  muscles  on  the  side 
opposite  the  deformity  firmly  with  the  view  of 
increasing  their  power  and  enabling  them  to  keep 
the  foot  in  position. 

These  manipulations,  however,  are  not  suffi- 
cient to  lead  to  a  permanent  cure,  and  in  the 
intervals  between  their  employment  the  foot 
should  be  fixed  in  its  normal  position,  or,  if 
possible,  in  one  in  which  the  deformity  is  some- 
what over-corrected  ;  a  constant  gentle  pressure 
is  thus  exerted,  and  the  soft  cartilaginous  bones 
are  gradually  moulded  into  their  normal  shape. 
In  the  early  stages  this  is  done  better  by  a 
light  splint  than  by  any  complicated  apparatus, 
which,  owing  to  the  small  size  of  the  foot,  is 
not  likely  to  keep  its  proper  place.  The 
splint  which  we  prefer  (see  Fig.  100),  consists  of 
a  light  metal  leg-piece  which  is  moulded  to  the 
back  of  the  leg  from  just  above  the  os  calcis  to  the 
upper  part  of  the  calf,  and  a  flat  foot-piece  cut 
to  the  shape  of  the  foot ;  these  two  portions  are 
connected  by  a  stout  copper  wire  bent  as  shown 

in  the  figure,  and  strong  enough  to  resist  the  action  of  the  muscles,  but 
at  the  same  time  pliable  enough  to  be  bent  by  the  nurse.  The  splint  is 
padded  with  chamois  leather,  and  the  wire  bent  so  that  the  splint  fits  the 
foot  whilst  the  latter  is  in  the  faulty  position.  The  foot  and  leg  are  then 
fastened  firmly  to  the  splint  by  bandages,  and  the  nurse  grasps  the 
foot-piece  with  one  hand,  and  the  leg-piece  with  the  other,  gradually 
bringing  the  splint,  and  with  it  the  foot,  into  its  normal  position  ;  after 
a  few  days  the  limb  may  be  brought  into  a  position  of  over-correction. 
The  copper  wire  connecting  the  two  portions  of  the  splint  is  sufficiently 
stout  to  retain  its  new  position,  and  resist  the  tendency  of  the  muscles 
to  reproduce  the  deformity. 

The  splint  should  be  taken  off  two  or  three  times  a  day  to  permit  of 
the  manipulations  referred  to  above,  and  should  be  bent  back  into  the 
faulty  position  before  being  re-applied ;  it  is  then  fixed  on  the  leg  and 
foot,  and  the  limb  afterwards  brought  into  the  over-corrected  position. 


FIG.  loi. — SPLINT  FOR 
TALIPES.  This  is  similar  to 
the  one  in  the  preceding  figure, 
except  that  it  has  a  projecting 
rim  along  the  inner  border  of 
the  foot-piece,  which  is  very 
useful  for  keeping  the  foot  in 
place. 


3i8  DEFORMITIES 

The  reasons  for  preferring  this  splint  to  plaster  of  Paris  are  given  on 
p.  348. 

It  is  also  advisable  to  employ  daily  massage  designed  to  maintain  the 
power  of  the  muscles,  which  are  to  some  extent  interfered  with  while  the 
limb  is  on  the  splint.  Benefit  may  be  obtained  from  the  galvanic  current 
when  the  muscular  action  is  feeble.  It  should  be  applied  daily,  for  about 
ten  minutes  at  a  time,  to  the  muscles  both  at  the  back  and  in  front  of  the 
limb.  When  the  child  is  old  enough  to  walk,  a  Scarpa's  shoe  (see  Fig.  117) 
may  be  employed ;  and,  in  addition,  exercises,  such  as  tiptoe  exercises, 
rising  on  the  outside  of  the  foot,  etc.,  varying  according  to  the  nature 
of  the  deformity,  should  be  practised.  More  detailed  information  upon 
these  points  is  given  in  connection  with  the  treatment  of  the  individual 
forms  of  club-foot. 

In  the  second  group  of  cases  there  are  structures  which  definitely 
resist  re-position  and  means  must  be  taken  to  overcome  them.  This  is 
best  done  by  the  use  of  a  tenotomy  knife.  The  methods  of  performing 
tenotomy  in  various  situations  are  referred  to  in  detail  in  connection  with 
the  individual  forms  of  club-foot.  The  resisting  structures  are  divided 
freely,  and  the  foot  is  put  up  on  a  suitable  splint  in  the  corrected  position, 
which  is  exchanged  later  on  for  one  of  over-correction.  Whether  com- 
plete correction  should  be  carried  out  at  once,  or  should  be  delayed  for 
a  few  days,  depends  upon  the  circumstances  of  the  case.  When  the 
contraction  is  extreme,  immediate  and  complete  correction  is  sometimes 
inadvisable,  especially  when  the  tendo  Achillis  is  affected,  for  if  immediate 
correction  be  made,  there  may  be  either  no  union  at  ah1  or  else  that  which 
occurs  may  be  long,  imperfect,  and  weak,  and  may  lead  to  a  deformity 
of  the  opposite  kind.  In  most  of  the  other  tendons,  however,  and 
in  all  cases  in  which  the  contraction  is  not  very  great,  there  is  a  con- 
siderable advantage  in  putting  up  the  foot  in  the  corrected  position 
immediately  and  substituting  a  position  of  over-correction  for  this  in 
a  few  days.  After  union  between  the  divided  ends  has  taken 
place,  as  it  usually  does  in  two  to  three  weeks,  careful  manipulations, 
massage,  electricity,  and  the  application  of  apparatus  should  be  begun. 
When  the  patient  is  old  enough  to  walk,  a  suitable  mechanical 
arrangement  permitting  the  use  of  the  joints  within  normal  limits 
should  be  combined  with  the  other  forms  of  treatment.  These  are 
referred  to  in  detail  in  connection  with  the  individual  forms  of  the 
deformity. 

The  plan  of  rectifying  the  deformity  in  this  group  of  cases  without 
any  cutting  operation  has  been  strongly  advocated  by  some  surgeons. 
The  foot  is  forcibly  wrenched  and  bent  against  a  firm  support,  until 
the  parts  are  so  stretched  that  the  deformity  is  over-corrected.  The 
foot  is  then  put  up  in  plaster  of  Paris  or  on  a  suitable  splint.  Although 
some  amount  of  forcible  stretching  and  wrenching  may  be  of  consider- 
able advantage  in  these  cases,  we  prefer  the  use  of  the  tenotomy  knife  as 


ACQUIRED  CLUB-FOOT  319 

being  more  precise  in  its  action  and  less   likely  to  do  serious  damage. 
With  forcible  wrenching  alone  the  bruising  is  very  severe. 

In  the  third  and  most  severe  class  of  eases  the  treatment  will 
vary  with  the  amount  of  deformity  present,  but  as  a  rule  division  of 
tendons,  fasciae,  and  ligaments,  and  the  subsequent  use  of  manipulations 
and  retentive  apparatus  are  not  sufficient,  and  extensive  operations,  in- 
volving division  of  numerous  ligaments  and  other  structures  about  the 
foot,  or  in  some  cases  even  the  removal  of  part  or  the  whole  of  the  affected 
bones  may  be  called  for.  The  precise  indications  for  the  various  opera- 
tions are  given  in  connection  with  the  different  forms  of  club-foot.  It  is 
in  the  severe  and  long-standing  cases  of  equino-varus  that  these  pro- 
cedures are  most  often  called  for,  but  they  are  sometimes  found  necessary 
in  other  varieties  of  club-foot  when  the  deformity  has  been  allowed  to 
remain  uncorrected  for  a  long  time. 


GENERAL  POINTS  IN  THE  TREATMENT  OF  ACQUIRED 

CLUB-FOOT. 

The  treatment  will  vary  considerably  with  the  particular  case  under 
notice.  For  example,  in  the  paralytic  form,  in  which  the  deformity  is 
primarily  due  to  paralysis  of  one  group  of  muscles,  with  unbalanced 
action  of  the  opposing  groups,  the  object  of  treatment  must  be  to  main- 
tain the  foot  in  its  proper  position,  and  to  restore  the  functions  of  the 
paralysed  muscles,  or  replace  them  by  suitable  apparatus.  In  the  early 
stages  of  this  form  it  is  always  easy  to  correct  the  deformity  without 
using  any  force  and  without  putting  any  muscles,  tendons,  or  fibrous 
structures  on  the  stretch.  When  the  deformity  has  been  allowed  to 
persist  for  a  considerable  time,  however,  shortening  of  certain  muscles 
and  fibrous  structures  takes  place,  and  these  must  be  divided  before  the 
foot  can  be  brought  into  position.  In  the  early  stage,  therefore,  the 
means,  already  indicated  (see  p.  314),  for  maintaining  and  improving  the 
nutrition  of  the  paralysed  muscles  must  be  adopted  ;  it  will  be  necessary 
in  addition  to  employ  some  apparatus  to  prevent  recurrence  of  the  de- 
formity. When  a  secondary  contraction  of  muscles,  fasciae,  or  ligaments 
has  taken  place,  tenotomy  will  be  called  for,  and  then  the  treatment  is 
much  the  same  as  in  the  second  group  of  congenital  cases  (see  p.  318). 

In  the  spastic  eases  the  treatment  is  directed  first  to  the  cure  of  the 
spasm,  which  unfortunately  is  not  easy.  Tenotomy  is  often  of  benefit 
especially  in  the  early  stages  ;  division  of  a  tight  tendon  not  only 
enables  the  foot  to  be  restored  to  its  proper  position,  but  seems  to  have 
a  curative  effect  upon  the  spasmodic  condition  itself.  Care  is  neces- 
sary in  the  after-treatment  to  prevent  undue  elongation  of  the  uniting 
medium. 

When  the  deformity  is  due  to  eieatrieial  contraction,  (e.g.  after  ulcers 


320  DEFORMITIES 

or  burns),  plastic  operations  may  be  required.  The  nature  of  the  opera- 
tion depends  so  much  upon  the  amount  and  position  of  the  contracted 
material  that  it  is  difficult  to  lay  down  any  special  rules.  In  these  cases 
prevention  is  the  only  really  satisfactory  treatment,  and  therefore  skin- 
grafting  should  be  employed  quite  early  in  all  ulcers  or  burns  of  any  size 
about  the  lower  third  of  the  leg,  and  a  suitable  apparatus  applied  so  as  to 
prevent  the  contraction  which  is  otherwise  certain  to  follow  cicatrisation. 
When  contraction  has  occurred  and  has  lasted  some  time,  the  muscles 
become  shortened  and  the  fascia  tense,  and,  even  although  the  cicatrix 
which  was  the  original  cause  of  the  trouble  be  dissected  away,  the 
mal-position  of  the  foot  is  not  relieved  thereby,  and  some  more  radical 
operation  must  be  undertaken  for  its  rectification.  Sometimes  it  is 
possible  to  dissect  away  the  scar  and  the  deep  fascia,  and  to  bring  the 
foot  into  position  by  manipulations,  wrenching  or  division  of  tendons  or 
fasciae.  Further,  recurrence  of  the  deformity  may  be  avoided  by  employ- 
ing skin-grafting  and  keeping  the  foot  in  the  over-corrected  position 
during  the  healing  process  and  for  some  time  afterwards.  In  many 
cases,  however,  it  is  impossible  to  bring  the  foot  into  proper  position  in 
spite  of  free  removal  of  the  cicatrix  and  the  fascia,  followed  by  wrenching  ; 
if  the  disability  caused  by  the  deformity  be  very  great  it  will  be  necessary 
to  resort  to  some  more  severe  procedure,  such  as  removal  of  portions  of 
bones,  or  even  amputation. 

In  bad  cicatricial  deformities  about  the  back  and  sides  of  the  leg  in 
the  neighbourhood  of  the  ankle  joint,  removal  of  an  inch  or  two  of  the 
tibia  and  fibula  will  sometimes  enable  the  foot  to  be  brought  to  a  right 
angle,  or  even  actually  into  its  normal  position.  The  result,  however, 
is  not  quite  satisfactory  as  a  rule  for  two  reasons  :  in  the  first  place  the 
contraction  extends  to  the  ankle  joint  itself,  so  that  the  rigidity  of  the 
parts  in  the  neighbourhood  of  the  joint  may  still  prevent  the  foot  being 
brought  into  proper  position,  even  when  the  leg  has  been  shortened  suffi- 
ciently to  prevent  the  contracted  tissues  from  displacing  the  foot;  in 
the  second  place  it  is  very  difficult  to  get  the  foot  into  position  after  the 
bones  of  the  leg  have  been  divided,  for  the  lower  fragments  of  the  tibia 
and  fibula  are  so  short  that  it  is  impossible  to  get  a  proper  purchase  upon 
them  in  order  to  move  the  ankle  joint,  and  break  down  adhesions  in  it. 
This  operation,  however,  has  been  done  with  marked  benefit ;  the  cases  in 
which  it  is  most  likely  to  be  successful  are  those  in  which  there  is  a 
certain  amount  of  movement  in  the  ankle  when  the  knee  is  fully  flexed, 
so  that  the  front  of  the  foot  can  be  brought  up  to  some  extent.  In  the 
majority  of  these  cases  the  main  deformity  is  that  of  talipes  equinus, 
with  possibly  a  little  tendency  to  varus,  and  therefore  it  is  more  a 
question  of  getting  the  foot  to  a  right  angle  than  of  overcoming  any 
lateral  displacement. 

This  operation  is  done  through  a  vertical  incision  along  the  anterior 
border  of  the  tibia,  and  a  second  one  along  the  outer  aspect  of  the  fibula ; 


TALIPES  EQUINUS  321 

the  periosteum  is  separated  and  the  requisite  amount  of  bone  removed. 
It  is  well  to  make  the  section  of  the  tibia  oblique,  so  as  to  provide  a  larger 
surface  for  coaptation  and  fixation.  The  fibula  should  be  cut  across  with 
bone  forceps  or  a  saw  in  the  first  instance,  and  when  the  required  amount 
of  the  tibia  has  been  removed  it  will  be  seen  how  much  of  the  fibula  must 
be  excised.  Full  details  of  the  methods  of  fixing  the  ends  of  the  bone 
are  given  in  connection  with  Ununited  Fractures  (see  Vol.  II.).  The  limb 
should  be  put  up  with  the  foot  at  a  right  angle,  and  any  lateral  displace- 
ment remedied  by  side  splints  ;  in  a  fortnight  the  splints  may  be  replaced 
by  a  suitable  plaster  of  Paris  casing  which  should  be  kept  on  for  at 
least  eight  weeks.  Owing  to  the  slowness  with  which  union  occurs  under 
these  circumstances  it  is  impossible  to  dispense  with  the  apparatus  earlier, 
and,  owing  to  the  liability  to  non-union  after  an  operation  of  this  kind, 
it  is  useless  to  attempt  to  promote  the  movements  of  the  ankle  joint  until 
the  union  of  the  bones  of  the  leg  is  complete.  As  soon  as  this  has  occurred, 
passive  movement  must  be  begun,  and  it  will  usually  be  found  that  the 
degree  of  mobility  present  in  the  ankle  before  the  operation  will  still 
remain .  Careful  movement  and  massage,  and  later  on  forcible  movements 
under  an  anaesthetic,  may  possibly  increase  the  range  of  movement  thus 
obtained. 

When  the  ulceration,  or  the  burn,  is  situated  upon  the  foot  itself,  the 
bone  calling  for  removal  will  generally  be  the  astragalus,  but  the  actual 
operation  required  will  depend  upon  the  nature  of  the  deformity  and  the 
situation  of  the  cicatrix.  In  some  cases  amputation  will  be  the  better 
practice,  but  no  definite  rules  can  be  laid  down,  on  account  of  the  great 
variety  of  conditions  that  may  be  met  with. 

THE  INDIVIDUAL  FORMS  OF  CLUB-FOOT. 

TALIPES   EQUINUS. 

In  this  form  the  heel  is  drawn  up  and  the  toes  are  pointed.  The 
condition  is  rarely  congenital ;  it  usually  results  from  some  inflamma- 
tion in  the  calf  muscles  or  in  their  vicinity,  which  leads  to  their  contrac- 
tion. It  may  also  be  a  sequel  to  infantile  paralysis  affecting  the  anterior 
group  of  leg  muscles,  cicatricial  contraction  of  ulcers  or  wounds  in  the 
calf  of  the  leg,  or  to  pointing  of  the  foot  during  a  long  illness,  in  which 
care  has  not  been  taken  to  keep  the  pressure  of  the  bed-clothes  off  the 
toes.  It  may  also  occur  in  connection  with  disease  of  the  ankle  or  the 
tarsal  joints  in  which  a  secondary  contraction  of  the  muscles  of  the  calf 
has  occurred. 

Talipes  equinus  varies  in  degree  ;  sometimes  the  heel  may  be  drawn 
up  to  such  an  extent  that  the  sole  of  the  foot  is  almost  in  the  same  plane 
as  the  back  of  the  leg  ;  sometimes  the  chief  trouble  is  that  the  foot 
cannot  be  dorsi-flexed  beyond  a  right  angle.  In  the  severe  cases  the 


322  DEFORMITIES 

patient  walks  upon  the  balls  of  the  toes,  the  phalanges  of  which  are 
generally  hyper-extended  upon  the  metatarsals  by  the  pull  of  the  ex- 
tensor muscles  ;  locomotion  is  interfered  with,  partly  by  the  increased 
length  of  the  lower  extremity  and  the  small  basis  upon  which  the  patient 
stands,  and  partly  by  the  formation  of  callosities  and  bursae  over  the 
ends  of  the  metatarsal  bones,  and  the  frequent  attacks  of  inflammation 
and  suppuration  which  their  presence  entails. 

In  the  milder  cases  the  sole  is  applied  normally  to  the  ground  when 
the  patient  stands,  but  in  the  act  of  walking  the  weight  is  borne  mainly 
upon  the  front  half  of  the  foot,  the  heel  being  drawn  up  off  the  ground 
to  a  slight  extent.  This  causes  the  patient  to  limp,  and  gives  rise  to  pain 
in  the  back  of  the  leg  and  about  the  heel  which  is  due  to  stretching  of  the 
calf  muscles. 

In  the  slighter  cases  and  in  those  in  which  the  deformity  has  lasted  only 
a  short  time,  the  essential  obstacle  to  the  reduction  of  the  deformity 
is  the  undue  tension  of  the  tendo  Achillis.  When  the  deformity  is  more 
marked,  and  particularly  when  it  has  lasted  for  a  considerable  time, 
certain  secondary  changes  take  place.  In  very  long-standing  cases, 
especially  those  in  which  the  deformity  is  extreme,  the  upper  articular 
surface  of  the  astragalus  becomes  altered  both  in  shape  and  structure. 
The  chief  change  takes  place  anteriorly,  where  the  cartilage  which  normally 
covers  it  becomes  converted  into  fibrous  tissue,  and  that  portion  of  the 
articular  surface  which  the  new  position  of  the  foot  has  forced  out  of 
contact  with  the  lower  end  of  the  tibia  becomes  enlarged,  so  that  it  is 
impossible  for  the  astragalus  to  pass  back  into  position,  even  when  all 
the  causes  producing  the  deformity  have  been  removed. 

Another  important  change  is  contraction  of  the  plantar  fascia,  which 
leads  to  an  exaggeration  of  the  arch  of  the  instep,  and  ultimately  pro- 
duces the  condition  known  as  talipes  cavus,  or  hollo\v  club-foot  (see  p.  334). 
This  causes  pain  in  the  sole  on  walking,  due  to  stretching  of  the  shortened 
plantar  fascia ;  callosities  also  develop  over  the  heads  of  the  metatarsal 
bones  and  give  rise  to  pain.  In  some  cases  also,  permanent  shortening  of 
the  long  flexors  of  the  toes  and  of  the  peroneus  longus  takes  place,  whilst, 
in  addition,  inversion  of  the  foot  at  the  mid-tarsal  joint  may  occur,  pro- 
ducing a  condition  of  talipes  equino-varus. 

TREATMENT. — From  the  point  of  view  of  treatment  talipes 
equinus  may  be  divided  into  three  classes,  (i)  The  mild  cases,  in  which 
the  foot  cannot  be  dorsi-flexed  beyond  a  right  angle,  but  in  wrhich  there 
is  no  contraction  of  any  other  structures  than  the  calf  muscles. 

(2)  The  more  severe  cases,  in  which  the  heel  is  considerably  drawn  up 
and  in  which  there  is  also  secondary  contraction  of  other  structures, 
such  as  the  plantar  fascia,  and  possibly  also  some  of  the  muscles  already 
mentioned. 

(3)  The  most  severe  cases  of  all,  in  which  the  elevation  of  the  heel  is 
extreme,  and  in  which  the  affection  has  lasted  long  enough  for  profound 


TALIPES   EQUINUS  323 

alterations  to  have  occurred  in  the  bones  and  the  articular  surfaces  ; 
in  these  cases,  re-position  of  the  foot  is  extremely  difficult. 

In  the  first  group,  the  tendo  Achillis  should  be  divided,  and  then 
the  foot  maintained  in  position  by  suitable  apparatus  and  suitably 
exercised  meanwhile.  Some  authorities  employ  exercises  alone  so  as  to 
stretch  the  calf  muscles  gradually,  and  advise  that  tenotomy  should  not 
be  done.  In  some  cases  it  may  be  possible  to  overcome  the  trouble  in 
this  way,  but  on  the  whole  it  is  neither  a  satisfactory  nor  a  safe  procedure. 
The  constant  pulling  upon  a  tight  tendon  may  set  up  spastic  contraction 
in  the  calf  muscles,  and  lead  to  a  fibroid  thickening  in  the  muscles — both 
conditions  being  likely  to  increase  the  contraction.  On  the  other  hand, 
division  of  the  tendo  Achillis  is  followed  by  such  satisfactory  results  that 
there  is  no  reason  to  adopt  a  longer,  more  painful,  and  less  certain  method. 

The  operation  is  performed  as  follows.  The  limb  is  turned  over  upon 
its  outer  side  and  steadied  upon  a  sandbag,  and  the  surgeon  introduces  a 
tenotomy  knife  through  the  skin  on  one  side  of  the  tendo  Achillis — for 
choice  on  the  inner  side.  The  tenotomy  knife  should  be  very  sharp,  with 
a  cutting  edge  not  more  than  half  an  inch  long  ;  the  rest  of  the  blade 
should  be  rounded,  narrow,  and  blunt,  so  as  to  lie  in  the  small  skin 
puncture  made  by  the  cutting  portion  without  increasing  it.  Authorities 
are  not  agreed  whether  this  or  any  tendon  should  be  divided  by 
introducing  the  knife  along  the  deeper  surface  of  the  tendon  and  cutting 
towards  the  skin,  or  by  insinuating  the  knife  between  the  skin  and 
the  tendon,  and  cutting  towards  the  deeper  structures.  The  objec- 
tions urged  against  the  former  procedure,  which  is  the  one  more  often 
adopted,  are  of  considerable  importance.  .  In  the  first  place  it  is  easy  to 
include  between  the  knife  and  the  skin  vessels  or  nerves,  which  must  then 
be  inevitably  divided  along  with  the  tendon  ;  in  the  second  place,  the 
surgeon,  in  his  anxiety  to  avoid  the  inclusion  of  these  structures  between 
the  knife  and  the  tendon,  is  apt  to  puncture  the  latter,  and  to  leave 
some  fibres  undivided — an  occurrence  which  would  render  the  whole 
operation  nugatory ;  in  the  third  place,  when  the  last  fibres  are  divided, 
and  the  tendon  gives  way  suddenly  under  the  knife,  the  latter  is  apt  to  be 
thrust  through  the  skin,  and  thus  to  convert  a  subcutaneous  operation 
into  an  open  one.  As  a  matter  of  fact,  many  surgeons  employ  two 
knives  with  the  view  of  avoiding  the  latter  accident  ;  the  first  is  sharp- 
pointed  and  makes  the  track,  and  the  other  is  blunt-pointed  and  is  intro- 
duced along  the  track,  after  withdrawal  of  the  first,  and  made  to  divide 
the  tendon.  This,  however,  is  an  unnecessary  complication,  the  more 
so  as  it  is  not  easy  to  push  the  blunt  instrument  along  the  track  made  by 
the  sharp  one.  The  chief  objection  urged  against  division  of  the  tendon 
from  without  inwards  is  that  the  knife  may  divide  important  structures 
beneath  as  the  tendon  gives  way  ;  most  of  these  structures  lie  in  soft 
mobile  tissues,  however,  and  yield  before  the  point  of  the  knife,  so  that  an 
accident  of  this  kind  very  seldom  occurs.  We  prefer  to  divide  tendons 


Y  2 


324 


DEFORMITIES 


by  cutting  from  the  skin  surface  downwards  as  it  is  a  method  by  which 
one  can  be  certain  of  not  leaving  any  fibres  undivided,  whilst  accidental 
enlargement  of  the  skin  opening  is  certainly  avoided.  It  must  be  con- 
fessed, however,  that  enlargement  of  the  skin  wound  is  nowadays 
of  little  consequence  ;  at  the  same  time  it  is  best  avoided,  because  the 
scar  in  the  skin  may  become  adherent  to  the  cicatricial  tissue  between 


FIG.  102. — THE  METHODS  OF   DIVIDING  THE  TENDO  ACHILLIS   SUBCUTANEOUSLY. 

A.  Division  of  the  tendon  from  its  deep  surface  towards  the  skin.     The  tenotomy 
knife  is  here  introduced  on  the  outer  side  at  right  angles  to  the  skin,  and  is  thrust  across 
in  front  of  the  anterior  surface  of  the  tendon  until  its  point  is  just  beneath  the  skin  on 
the  inner  side,  where  the  surgeon  notes  its  position  with  the  left  forefinger.     In  the 
drawing  the  assistant  is  in  the  act  of  making  the  tendon  tense  for  the  surgeon   to 
divide  it.     It  is  more  usual  to  introduce  the  knife  from  the  inner  side. 

B.  Division  of  the  tendon  from  its  superficial  surface  towards  the  bone.     This  is  the 
method  we  prefer  and  have  described  in  the  text.     In  the  drawing  the  point  of  the 
tenotome  is  shown  as  it  is  being  insinuated  between  the  skin  and  the  tendon  ;   the 
surgeon  notes  its  progress  beneath  the  skin  by  means  of  the  left  thumb  or  forefinger. 
The  parts  are  represented  as  being  fully  relaxed  by  the  assistant  in  order  to  facilitate  the 
passage  of  the  tenotome  across  the  back  of  the  tendon. 

In  both  drawings  the  surgeon's  hands  are  denoted  by  the  letters  o,  o,  while  those  of 
the  assistant  are  marked  a,  a.     (After  Hoffa.) 


the  divided  ends  of  the  tendon,  and  thus  hamper  the  movements  of  the 
latter. 

In  division  of  the  tendo  Achillis,  the  knife  should  be  introduced  on 
the  inner  side  of  the  tendon,  about  half  an  inch  beyond  its  margin  and 
about  an  inch  above  its  insertion  into  the  os  calcis  ;  the  blade  should  lie 
flatwise  on  the  tendon.  In  fat  children  it  is  not  always  easy  to  define 
the  edge  of  the  tendon,  and  in  them  it  is  best  to  make  the  puncture  about 
midway  between  the  inner  border  of  the  tibia,  which  can  always  be  felt, 
and  the  back  of  the  leg.  The  foot  is  given  in  charge  of  an  assistant  who 


TALIPES  EQUINUS 


325 


makes  the  tendon  prominent  by  dorsi-flexing  the  foot  whilst  the  puncture 
in  the  skin  is  being  made  ;  as  soon  as  this  has  been  done,  however,  the 
tendon  is  relaxed  by  depressing  the  front  of  the  foot  in  order  to  enable  the 
surgeon  to  insinuate  his  knife  more  readily  between  it  and  the  skin.  The 
surgeon  ascertains  the  progress  of  his  knife  as  he  insinuates  it  between  the 
skin  and  the  back  of  the  tendon  by  means  of  his  left  fore-finger,  and  makes 
sure  that  no  tendinous  fibres  are  left  between  the  knife  and  the  skin 
(see  Fig.  102).  When  the  point  has  been  passed  well  across  to  the  opposite 
border  of  the  tendon,  the  cutting  edge  is  turned  forward,  and  then  the 


FIG.  103. — DIAGRAM  SHOWING  THE  STRUCTURES  NEEDING  Division  IN  TALIPES 
EQUINO-VARUS.  (a)  Tibialis  posticus  tendon,  (ft)  Tendo  Achillis.  (c)  Anterior  por- 
tion of  the  deltoid  ligament,  (d)  Tibialis  anticus  tendon,  (e)  Plantar  fascia. 

assistant  puts  the  tendon  firmly  upon  the  stretch  once  more  whilst  the 
surgeon  presses  the  knife  against  it  and  divides  it  with  a  steady,  light 
sawing  movement ;  when  the  division  is  complete,  the  tendon  gives  way 
suddenly  and  a  gap  appears  between  the  divided  ends.  Before  with- 
drawing his  knife,  the  surgeon  should  ascertain  with  his  left  fore-finger 
that  there  are  no  other  tight  structures  requiring  division  ;  sometimes  the 
sheath  of  the  tendon  is  also  contracted  and  requires  to  be  nicked.  The 
principal  reason  for  dividing  the  tendo  Achillis  at  the  spot  recommended, 
namely  an  inch  above  its  insertion  into  the  os  calcis,  is  that  division  at  a 
lower  point  is  not  always  satisfactory,  because  a  series  of  tendinous  slips 
are  often  given  off  at  about  that  spot,  to  be  inserted  into  the  upper  part 
of  the  os  calcis,  and  proper  relaxation  of  the  tendon  will  not  occur  if  they 
escape  division.  When  the  tendon  has  been  divided,  the  foot  should  be 


326  DEFORMITIES 

forcibly  dorsi-flexed  two  or  three  times,  so  as  to  stretch  or  tear  through 
any  other  tight  bands. 

It  is  rarely  that  any  accidents  happen  during  the  performance  of  this 
small  operation.  There  may  be  bleeding  from  division  of  the  short 
saphena  vein,  but  this  soon  stops  with  light  pressure.  Puncture  of  the 
posterior  tibial  artery  is  extremely  rare  ;  should  it  occur,  the  best  plan  is 
to  enlarge  the  skin  incision,  and  expose  and  tie  the  divided  ends.  Some 
surgeons,  however,  apply  firm  pressure  by  means  of  a  pad  over  the 
bleeding  vessel  in  the  first  instance,  and  then  adopt  appropriate  treat- 
ment later  should  a  false  aneurysm  form.  At  the  same  time  one  need 
not  cut  down,  merely  because  arterial  blood  spouts  from  the  wound  when 
the  foot  is  moved ;  this  may  come  from  some  small  vessel,  and  will  be 
arrested  by  the  application  of  a  pad  and  bandage.  Should  the  wound  in 
the  skin  be  made  too  large  by  an  accidental  slip  of  the  knife,  its  edges 
should  be  brought  together  with  a  stitch  or  two.  The  disadvantage 
of  a  large  skin  incision  nowadays  is  not  the  risk  of  sepsis,  but  the  possi- 
bility of  adhesion  of  the  scar  to  the  new  material  thrown  out  between  the 
ends  of  the  tendon. 

After-treatment. — The  next  point  that  arises  is  whether  the  foot  should 
be  put  up  in  the  over-corrected  position  at  once  or  whether  it  should  be 
left  for  a  few  days  in  its  faulty  position  until  a  certain  amount  of 
reparative  material  has  been  thrown  out  between  the  divided  ends 
of  the  tendon.  The  answer  to  this  question  depends  upon  the  degree  of 
deformity  present. 

In  the  milder  cases,  in  which  the  gap  left  after  tenotomy  is  less  than 
two  inches,  the  foot  may  be  put  up  at  once  at  right  angles  upon  a  suitable 
splint,  such  as  the  one  already  described  (see  Fig.  100).  A  small 
pad  of  gauze  is  fixed  over  the  puncture  with  collodion,  and  care  must 
be  taken  that  the  bandage  fastening  the  limb  to  the  splint  does  not  press 
upon  the  gap  between  the  divided  ends,  lest  the  formation  of  plastic 
material  between  the  ends  be  interfered  with.  From  the  second  day 
onwards  the  deformity  is  gradually  over-corrected  by  slowly  increasing 
the  dorsal  flexion  of  the  foot  until,  in  about  a  week,  its  extreme  limit  is 
reached.  The  foot  is  then  fixed  in  plaster  of  Paris  in  this  over-corrected 
position  for  another  fortnight. 

In  three  weeks  from  the  operation  the  splint  or  plaster  of  Paris  casing 
should  be  abandoned,  and  the  limb  massaged,  while  the  patient  is  en- 
couraged to  carry  out  exercises 'designed  to  develop  the  muscles  that  are 
at  fault.  It  is  of  special  value  to  make  the  patient  perform  active  move- 
ments against  resistance  which  is  gradually  increased  as  the  muscular 
power  improves.  By  this  time  the  uniting  material  will  be  sufficiently 
firm  to  connect  the  ends  of  the  tendons ;  it  is,  however,  not  yet 
strong,  but  the  patient  may  be  allowed  to  walk  about,  provided  that 
he  walks  on  the  flat  of  the  foot  and  does  not  put  much  strain  upon 
the  tendon. 


TALIPES  EQUINUS 


32? 


At  a  later  stage  the  following  arrangement  will  be  found  of  value. 
A  piece  of  wood  of  suitable  size  and  thickness,  long  enough  to  extend 
from  the  heel  to  at  least  three  inches  beyond  the  tips  of  the  toes,  is  cut 
to  the  shape  of  the  foot.  A  piece  of  strapping,  between  two  and  three 
inches  broad,  and  sufficiently  long  to  reach  from  the  middle  of  the  thigh 
to  the  toes  and  then  twice  the  length  of  the  splint,  is  applied  first  to  the 
upper  surface  of  the  splint,  beginning  near  its  anterior  extremity,  carried 
along  the  upper  surface,  round  the  posterior  edge,  and  then  along  the  lower 


FIG.  104. — SAYRE'S  APPARATUS  FOR  USE  AFTER  TENOTOMY  OF  THE  TENDO  ACHILLIS. 
The  method  of  application  is  given  sufficiently  in  detail  in  the  text.  The  smaller  sketch 
above  is  to  illustrate  the  method  of  fastening  the  strapping  to  the  foot-piece  of  the  splint  ; 
it  will  be  seen  that  it  commences  on  the  upper  surface  of  the  splint  near  its  anterior 
margin,  runs  backwards  along  the  upper  surface,  down  round  the  posterior  edge  and 
finally  runs  forward  along  the  under  surface  and  round  the  anterior  margin  of  the  splint, 
where  it  terminates  in  a  long  free  end  which  is  shown  applied  to  the  thigh  in  the  larger 
drawing.  The  length  of  the  foot-piece  varies  ;  the  more  leverage  it  is  desired  to  exert 
the  further  should  it  project  beyond  the  toes. 


surface  and  over  the  anterior  edge  again.  This  part  of  the  strapping  is 
then  bound  firmly  to  the  splint  by  two  or  three  transverse  pieces  of 
strapping  (see  Fig.  104).  The  splint  thus  prepared  is  padded,  and  fastened 
at  the  heel,  sandalwise,  by  a  broad  strip  of  strapping  passing  around  the 
instep  and  the  posterior  end  of  the  splint ;  the  splint  is  then  secured  to 
the  foot  by  a  bandage.  The  long  end  of  the  strapping  which  hangs  over 
from  the  front  of  the  splint  is  now  applied  along  the  front  of  the  thigh,  the 
foot  meanwhile  being  held  at  right  angles  and  the  knee  fully  extended. 
The  strapping  is  fastened  by  a  bandage  commencing  just  below  the 
patella  and  carried  up  to  the  centre  of  the  thigh.  The  free  end  of  the 
strapping  is  turned  down  over  the  upper  edge  of  the  bandage,  and 


328 


DEFORMITIES 


the  latter  is  carried  downwards  over  it ;  in  this  way  the  strapping  and 
the  bandage  are  firmly  fastened  to  the  skin  of  the  thigh.  Should  the 
strapping  slip,  as  it  generally  does  after  two  or  three  days,  a  second 
bandage  applied  over  the  old  one  and  carried  down  rather  further  below 
the  patella  will  keep  it  taut.  The  patient  should  be  encouraged  to  walk 
wearing  this  apparatus ;  leverage  is  exerted  upon  the  ankle  joint  as  the 
patient  walks,  as  the  splint  is  longer  than  the  foot,  and  the  latter  is  bent 
far  more  effectually  than  if  a  boot  wrere  worn.  The  apparatus  leaves  the 

calf  muscles  free,  and  massage 
can  be  applied  to  them ;  it 
generally  requires  to  be  renewed 
about  once  a  week. 

After  about  six  weeks,  more 
vigorous  exercises  should  be 
commenced  and  carried  out 
while  the  patient  is  wearing 
the  splint  just  described.  The 
following  is  of  considerable 
value.  The  patient  stands  up- 
right, the  heels  together,  and 
the  soles  flat  on  the  ground, 
and  he  then  sinks  downward, 
flexing  the  knees  and  hips  until 
he  is  able  to  touch  the  ground 
with  the  tips  of  the  fingers, 
when  he  again  resumes  the 
upright  position.  This  should 
be  done  a  dozen  times  in  suc- 
cession, and  repeated  several 
times  during  the  day.  At  the 
same  time  massage  and  gal- 
vanism should  be  applied  to  the 
calf  muscles.  After  about  eight 
weeks  from  the  operation  it  is 

well  to  employ  a  surgical  boot,  furnished  with  lateral  irons  attached  to  a 
band  passing  around  the  upper  part  of  the  leg,  and  made  with  a  hinge 
opposite  the  ankle  joint,  fitted  with  a  stop  to  prevent  the  foot  being  plantar- 
flexed  beyond  the  right  angle.  It  is  well  to  have  the  sole  of  this  boot  made 
somewhat  longer  than  the  foot,  for  it  then  acts  in  a  manner  similar  to  the 
splint  described  above,  and  exerts  a  greater  leverage  than  if  it  were 
the  exact  length  of  the  foot.  This  boot  is  more  sightly  and  convenient 
than  the  splint,  and  may  with  advantage  be  fitted  with  a  spring  which 
tends  to  keep  the  toes  raised  and  the  heel  depressed  (see  Fig.  105) ;  this  is 
especially  necessary  when  the  calf  muscles  were  much  contracted  prior  to 
tenotomy. 


FIG.  105. — BOOT  FOR  USE  AFTER  TENOTOMY  OF  THE 
TENDO  ACIULLIS.  The  dotted  line  shows  the  position  the 
boot  tends  to  assume  when  the  foot  is  off  the  ground  ;  it 
thus  continuously  stretches  the  tendo  Achillis.  The  boot 
should  be  made  a  good  deal  longer  than  the  foot,  and  it 
should  have  a  stop  at  the  ankle-joint  hinge  to  prevent  the 
toes  being  pointed.  (Hof?a.) 


TALIPES   EQUINUS  329 

In  the  more  severe  cases,  in  which  there  is  an  interval  of  two  inches  or 
more  between  the  divided  ends  of  the  tendon  when  the  foot  is  fully  plantar- 
flexed,  the  uniting  medium  between  the  cut  ends  would  probably  be  thin 
and  soft  if  the  deformity  were  corrected  immediately,  and  there  would 
certainly  be  a  risk  of  imperfect  union  ;  in  other  words,  a  condition  of 
talipes  calcaneus  might  be  substituted  for  that  of  equinus.  Under  these 
circumstances,  therefore,  the  limb  should  be  put  on  a  splint  in  the  uncor- 
rected  position  and  left  for  three  days,  so  as  to  allow  plastic  material  to 
be  poured  out  between  the  divided  ends.  On  the  third  day  a  slight 
correction  of  the  position  may  be  made,  and  a  slight  further  correction  is 
made  every  day  until  the  foot  has  been  brought  to  a  right  angle  at  the  end 
of  a  week  or  ten  days.  In  another  week  or  ten  days  this  is  increased  up 
to  the  extreme  limit  of  dorsal  flexion,  so  that  the  deformity  is  fully  over- 
corrected.  A  plaster  of  Paris  casing  is  then  applied  for  three  weeks,  after 
which  the  Sayre's  apparatus  (Fig.  104),  massage  and  exercises  may  be 
employed,  just  as  in  the  milder  cases. 

In  these  cases  also  a  surgical  boot  should  be  substituted  for  the  Sayre's 
apparatus  after  the  latter  has  been  worn  for  a  month  or  six  weeks,  and 
if  these  precautions  be  followed,  the  uniting  material  between  the  cut  ends 
of  the  tendo  Achillis  will  be  as  broad  and  firm  as  it  is  in  the  milder  cases, 
and  the  limb  will  be  thoroughly  useful. 

\Yhen  all  the  muscles  that  produce  dorsi-flexion  of  the  foot  are  para- 
lysed and  do  not  show  any  sign  of  recovery  after  division  of  the  tendo 
Achillis  and  correction  of  the  equinus,  there  will  be  a  continual  tendency 
for  the  toes  to  drop  and  the  equinus  to  recur.  This  must  be  guarded 
against  either  by  making  the  patient  wear  a  surgical  boot  (vide  supra) 
indefinitely  or  by  transplantation  or  grafting  of  the  tendon  of  a  healthy 
muscle,  such  as  the  tibialis  posticus,  on  to  the  front  of  the  foot,  so  as  to 
make  it  act  as  a  dorsi-flexing  agent.  The  subject  of  transplantation  of 
muscles  is  dealt  with  in  connection  with  the  affections  of  muscles. 

In  the  second  group  of  cases,  in  which  changes  other  than  the 
shortening  of  the  calf  muscles  occur,  the  secondary  contractions  must 
be  remedied  before  the  tendo  Achillis  is  divided.  The  most  important 
contraction  is  that  of  the  plantar  fascia,  the  dense  central  portion  of 
which  is  most  commonly  affected. 

Division  of  the  plantar  fascia  should  be  practised  and  the  foot  unfolded 
some  weeks  before  the  tenotomy  of  the  tendo  Achillis  is  done.  Should 
the  latter  structure  be  divided  at  the  same  time  as  the  plantar  fascia,  it 
will  be  difficult  to  stretch  the  sole  sufficiently,  because  the  heel  is  not  fixed 
and  purchase  cannot  be  taken  from  it ;  if  the  tendon  be  left  undivided,  a 
satisfactory  point  d'appui  is  obtained.  The  plantar  fascia  is  divided 
by  putting  the  sole  of  the  foot  firmly  upon  the  stretch,  and  dividing  all 
the  contracted  bands-with  a  tenotomy  knife  as  far  back  towards  the  heel 
as  is  convenient.  The  patient  is  anaesthetised,  and  special  care  is  taken  in 
the  disinfection  on  account  of  the  thick  skin  in  this  region  ;  the  anterior 


330 


DEFORMITIES 


half  of  the  foot  is  strongly  abducted  so  as  to  make  the  fascia  tense,  whilst 
the  tenotomy  knife  is  introduced  between  the  skin  and  the  fascia  about 
half  an  inch  to  one  side  of  the  most  prominent  tense  band,  and  at  about 
the  same  distance  in  front  of  the  tuberosity  of  the  os  calcis.  As  soon  as 
the  point  of  the  instrument  is  introduced  through  the  skin,  the  pressure 
upon  the  sole  is  relaxed,  and  the  knife  is  insinuated  between  the  skin  and 
the  fascia  with  the  blade  held  parallel  to  the  surface.  The  surgeon  should 
bear  in  mind  that  the  fascia  comes  very  close  to  the  skin,  and  is  often  in 
intimate  connection  with  it.  After  the  point  of  the  knife  has  been  pushed 
well  beyond  the  tight  band,  the  fascia  is  put  firmly  upon  the  stretch  once 

more,  the  cutting  edge  of  the  knife 
is  turned  towards  it,  and  made  to 
divide  it.  It  will  generally  be  found 
that  fresh  bands  start  into  promi- 
nence after  division  of  the  first,  and 
these  must  be  divided  methodically, 
either  from  the  same  puncture  or  from 
another  more  conveniently  placed. 
After  all  the  bands  have  been  divided, 
the  foot  should  be  stretched,  either 
with  the  hand  alone  or  with  a 
wrench.  If  the  foot  can  be  got  quite 
straight,  or  rather  into  the  over- 
corrected  position,  by  the  hand  alone, 
it  is  better  than  using  a  wrench,  as  less 
damage  is  done  to  the  tissues.  In 
many  cases,  however,  it  is  difficult 
to  stretch  the  sole  adequately  with 
the  hand  alone,  and  in  these  cases 
Thomas's  wrench  is  useful  (see  p.  352). 
After-treatment.  —  The  foot  should 
be  brought  into  the  over-corrected 

position,  the  small  punctures  dressed  with  gauze  and  collodion,  and 
the  metal  splint  (see  p.  316)  applied.  In  arranging  the  padding  of 
the  splint  care  must  be  taken  that  no  undue  pressure  is  exerted 
upon  the  heads  of  the  metatarsals ;  the  padding  should  be  thicker  in 
front  of  and  behind  the  balls  of  the  toes,  so  as  to  leave  a  depression 
into  which  they  may  sink.  Should  the  tendo  Achillis  allow  the  foot 
to  come  to  a  right  angle,  the  patient  may  be  allowed  to  stand, 
wearing  the  splint,  within  a  week  after  the  operation ;  the  stand- 
ing position  helps  to  promote  the  stretching  of  the  sole.  Should 
the  contraction  of  the  calf  muscles  be  very  great,  however,  this 
will  not  be  possible.  If  there  be  much  pain  complained  of  after  the 
operation,  the  splint  should  be  taken  off  and  the  padding  readjusted. 
This  is  an  important  matter,  for  serious  trouble  may  result,  should 


FIG.  106. — LINES  OF  INCISION  FOR  SUB- 
CUTANEOUS DIVISION  OF  THE  PLANTAR 
FASCIA. 


TALIPES  EQUINUS  331 

a  slough  form  on  the  balls  of  the  toes,  as  a  permanently  tender  scar  may 
be  left. 

In  many  cases  it  is  necessary  to  repeat  the  division  of  the  plantar 
fascia  some  three  or  four  weeks  after  the  first  operation.  In  no  case 
should  the  tendo  Achillis  be  divided  until  the  foot  has  been  unfolded 
and  the  sole  restored  to  its  normal  condition.  The  second  operation 
should  be  practised  further  forward  than  the  first,  so  as  to  divide  in- 
dividual slips  of  fascia  which  escaped  division  in  the  first  operation, 
and  which  have  become  tense  subsequently.  After  the  surgeon  is 
satisfied  that  the  sole  is  sufficiently  stretched  (usually  in  six  weeks  after 
the  treatment  has  been  begun),  the  tendo  Achillis  may  be  divided,  and 
the  subsequent  treatment  carried  out  as  for  the  first  stage  of  the  affection 
(seep.  326). 

In  the  most  severe  group  of  talipes  equinus  two  conditions  are 
met  with ;  either  simple  talipes  equinus,  in  which  the  heel  is  drawn  up  and 


FIG.  107. — EXCISION  OF  THE  ASTRAGALUS.    A  shows  the  incision  on  the  inner,  B,  that 
on  the  outer  side. 

the  sole  of  the  foot  is  fairly  straight,  or  very  severe  equinus  combined 
with  a  certain  amount  of  talipes  cavus.  We  shall  take  the  consideration 
of  the  former  group  first. 

(a)  It  is  well  to  commence  the  treatment  with  a  free  division  of  the 
plantar  fascia,  even  although  it  may  not  be  markedly  contracted.  In 
these  bad  cases  simple  division  of  the  tendo  Achillis  is  not  sufficient  to 
allow  the  foot  to  be  brought  into  its  proper  position.  This  is  due  partly 
to  contraction  of  the  ligaments  of  the  ankle  joint,  but  mainly  to  the 
alterations  which  have  occurred  in  the  anterior  part  of  the  upper  articular 
surface  of  the  astragalus.  In  most  cases  'the  surgeon  has  to  make  a 
choice  of  some  severe  operative  procedure,  but,  if  the  patient  be  young,  a 
few  weeks  may  be  devoted  with  advantage  to  ascertaining  whether,  after 
a  preliminary  division  of  the  plantar  fascia,  with  subsequent  division 
of  the  tendo  Achillis  and  the  posterior  ligament  of  the  ankle  joint,  con- 
tinuous upward  pressure  upon  the  front  of  the  foot  by  means  of  a  splint 
will  not  lead  to  a  cure.  If  the  deformity  be  not  overcome  after  a  fair 
trial  of  these  means  (which  are  those  described  for  the  treatment  of  the 
second  group  of  cases),  the  change  in  the  shape  of  the  astragalus  must 
be  remedied  if  possible.  The  operations  at  our  disposal  are  excision  of 


332  DEFORMITIES 

the  astragalus,  removal  of  a  portion  of  the  upper  surface  of  that  bone, 
excision  of  the  ankle  joint,  or  amputation. 

Excision  of  the  Astragalus. — In  ordinary  cases,  when  the  nutrition 
of  the  parts  is  good,  excision  of  the  astragalus  yields  an  excellent 
result,  and  is  probably  the  best  procedure.  After  this  operation  the  foot 
is  very  useful,  and  the  ankle  joint  is  freely  movable ;  the  os  calcis  rises 
to  some  extent  between  the  malleoli,  and,  when  the  operation  is  performed 
in  young  subjects,  it  is  almost  impossible,  when  they  reach  adult  life,  to 
tell  that  anything  has  been  done. 

Various  incisions  are  used  for  the  operation.  It  may  be  done  by  two 
vertical  incisions,  one  on  either  side  of  the  front  of  the  ankle  joint ;  that 
on  the  inner  side  commences  about  two  inches  above  the  internal  malle- 
olus,  over  the  anterior  border  of  the  tibia,  and  runs  downwards  over  the 
ankle  to  the  dorsal  surface  of  the  scaphoid.  This  incision  is  carried 
down  to  the  bone,  but  should  avoid  the  tibialis  anticus  tendon,  which 
is  easily  hooked  out  of  the  way.  The  second  incision  is  made  on  the 
outer  side ;  it  commences  about  two  inches  above  the  tip  of  the  external 
malleolus,  and  is  carried  downwards  and  forwards  parallel  with  the  inner 
incision  to  a  point  opposite  the  termination  of  the  latter  (see  Fig.  107). 
The  structures  over  the  front  of  the  ankle  joint  are  separated  by  a 
periosteum  detacher,  and  a  copper  spatula  is  passed  beneath  the  bridge 
of  soft  tissues  thus  raised,  which  contains  all  the  tendons,  vessels,  and 
nerves.  These  are  pulled  well  forwards  and  protected  against  injury 
by  the  spatula.  The  lateral  and  anterior  ligaments  of  the  ankle  joint 
are  now  divided  and  the  astragalo-scaphoid  articulation  is  opened.  The 
strong  calcaneo-astragaloid  ligament  is  next  divided,  and  then  the  astra- 
galus is  seized  by  strong  forceps  and  gradually  pulled  forwards  and  to 
one  side,  and  any  resisting  structure  divided.  At  the  posterior  part  of 
the  bone  the  tendon  of  the  flexor  longus  pollicis  must  be  separated  from 
its  groove  with  a  periosteum  detacher. 

A  simpler  method  is  by  means  of  a  single  long  incision,  commencing 
just  behind  the  fibula,  2^  inches  above  the  malleolus,  and  running  verti- 
cally down  as  far  as  the  tip  of  that  structure,  when  it  turns  forwards 
along  the  outer  aspect  of  the  foot  to  the  base  of  the  fifth  metatarsal. 
The  flap  is  dissected  up,  the  peronei  tendons  are  turned  out  of  their 
groove,  the  external  lateral* ligament  of  the  ankle  is  divided,  and  the 
head  of  the  astragalus  disarticulated  from  the  scaphoid.  By  inverting 
the  foot  forcibly,  the  strong  inter-osseous  ligament  between  the  os  calcis 
and  the  astragalus  can  be  divided,  and  the  latter  bone  freed  from  its 
remaining  connections  and  removed. 

After  the  astragalus  has  been  removed,  the  foot  is  put  up  at  a 
right  angle  upon  a  suitable  splint.  It  is  only  in  the  most  extreme  cases 
that  it  becomes  necessary  to  divide  the  tendo  Achillis  at  the  same 
time.  In  putting  up  the  foot  special  care  must  be  taken  to  prevent 
inversion,  and  the  best  apparatus  is  Croft's  plaster  of  Paris  splint, 


TALIPES  EQUINUS  333 

which  is  described  in  connection  with  fractures.  Lateral  poroplastic 
splints  moulded  to  the  foot  while  it  is  held  in  proper  position  are  also 
useful,  as  are  also  the  sterilised  wire-netting  splints  recommended  for 
fractures  (see  Vol.  II.). 

The  chief  point  to  remember  in  the  after-treatment  of  excision  of  the 
astragalus  is  that  there  is  a  tendency  to  inversion  of  the  foot  which  must 
be  carefully  guarded  against.  The  splint  should  be  kept  on  for  six  weeks 
when  the  patient  may  be  furnished  with  a  suitable  apparatus  and  allowed 
to  walk.  The  apparatus  should  consist  of  a  boot  to  which  are  attached 
lateral  irons  fastened  to  a  band 
around  the  upper  part  of  the 
leg  and  furnished  with  hinges 
opposite  the  ankle  joint  (see 
Fig.  108).  This  boot  should  be 
worn  for  eight  months  or  a 
year,  when  it  will  generally  be 
found  that  the  foot  has  become 
firm  in  its  new  position. 

Partial  Resection  of  the 
Astragalus. — When  the  defor- 
mity is  not  so  great,  it  may 
suffice  to  expose  the  front  of 
the  astragalus  by  incisions 
similar  to  those  just  described, 
and  to  chip  off  enough  bone 
from  its  upper  and  anterior 
surfaces,  with  a  chisel  or  a 
gouge  to  enable  the  articular 
surface  to  pass  beneath  the 
malleolar  arch,  and  then  to 
bring  the  foot  into  the  rect- 
angular position,  after  division 
of  the  tendo  Achillis.  This 

operation,  when  feasible,  is  perhaps  the  best  for  adult  cases,  but  in 
children  excision  of  the  astragalus  gives  such  perfect  results  that  it  is 
preferable.  If  removal  of  a  portion  of  the  astragalus  be  practised,  care 
must  be  taken  to  preserve  the  movements  of  the  ankle  joint  by  passive 
and  active  movements  and  massage.  The  movements  should  be  begun 
within  two  days  of  the  operation,  and  in  the  intervals  the  foot  should  be 
kept  on  a  posterior  splint  with  a  hinged  foot-piece  which  can  be  pushed 
up  so  as  to  over-correct  the  deformity. 

Amputation. — Amputation  is  rarely  called  for,  but  when  the  con- 
dition is  due  to  infantile  paralysis,  when  there  is  extreme  wasting  of 
the  parts,  when  the  nutrition  of  the  foot  is  markedly  interfered  with, 
when  the  latter  is  constantly  subject  to  ulceration,  and  when  in  fact  the 


FIG.  108. — BOOT  FOR  USE  AFTER  EXCISION  OF  THE 
ASTRAGALUS.  This  is  fitted  with  stout  lateral  leg-irons 
fastened  into  the  heel  below  and  furnished  with  a  hinge- joint 
opposite  the  ankle.  The  chief  object  of  the  apparatus  is  to 
prevent  inversion  of  the  foot. 


334  DEFORMITIES 

foot  would  be  useless  even  were  it  restored  to  its  proper  position,  amputa- 
tion will  be  far  more  satisfactory  than  an  attempt  to  retain  the  foot  and 
restore  its  functions  by  apparatus.  Amputation  of  the  leg  at  the  seat 
of  election  will  be  the  operation  of  choice  if  the  quadriceps  and  the 
hamstrings  are  not  paralysed  ;  if  they  are,  it  will  be  necessary  to  disarti- 
culate at  the  knee-joint  or  amputate  through  the  femoral  condyles. 

(6)  In  the  second  class  of  these  severe  cases  of  talipes  equinus, 
those,  namely,  in  which  there  is  marked  talipes  cavus,  the  treatment 
appropriate  for  the  latter  condition  must  be  employed  also  (vide  infra). 

TALIPES  CAVUS. 

Pes  cavus  is  an  acquired  deformity  usually  due  to  infantile  paralysis. 
It  is  due  to  a  dropping  of  the  front  of  the  foot,  with  secondary  con- 
traction of  the  plantar  fascia.  When  the  weight  is  borne  upon  the 
sole,  the  patient  generally  suffers  pain  from  stretching  of  the  plantar 
fascia  and  the  ligaments  ;  callosities  and  corns  form  over  the  metatarsal 
bones,  and  may  cause  great  suffering. 

Excision  of  a  Wedge  from  the  Tarsus. — Should  division  of  the  plantar 
fascia  (see  p.  329)  and  wrenching  fail,  it  may  become  necessary  to  remove 
a  portion  of  the  tarsus,  in  order  to  bring  the  sole  of  the  foot  flat  upon 
the  ground,  and  this  should  be  done  and  the  foot  brought  straight 
before  the  tendo  Achillis  is  divided.  The  operation  is  performed  through 
horizontal  incisions  along  the  inner  and  outer  sides  of  the  foot,  at  about 
the  level  of  the  scaphoid  bone  ;  these  are  carried  down  to  the  bone,  all 
the  soft  structures  being  peeled  off  the  plantar  and  dorsal  surfaces  of 
the  tarsus  with  a  periosteum  detacher.  The  soft  parts  are  held  aside  by 
copper  spatulae  introduced  between  them  and  the  bones,  and  a  wedge- 
shaped  portion  is  cut  from  the  tarsus  by  means  of  a  saw  insinuated  between 
the  spatulae  and  the  bone.  The  portion  of  bone  removed  should  have  its 
base  directed  towards  the  dorsum  of  the  foot,  and  its  apex  towards  the 
sole.  The  bones  should  be  removed  without  any  regard  to  their  articu- 
lations ;  the  block  excised  generally  consists  of  the  head  of  the  astragalus 
and  portions  of  the  scaphoid  and  cuboid.  When  the  dimensions  of  the 
wedge  have  been  judged  accurately  the  foot  can  be  brought  into  position  ; 
further  portions  of  the  bones  may  be  removed  with  a  chisel  should  there 
be  any  difficulty  in  doing  this. 

Division  of  the  plantar  fascia  and  wrenching  of  the  foot  should  be 
practised  before  the  soft  parts  are  separated  from  the  bones,  as  it  would 
be  impossible  to  do  this  after  the  bones  have  been  divided,  and,  therefore, 
more  bone  than  is  actually  necessary  would  have  to  be  taken  away.  The 
size  of  the  wedge  should  be  such  as  to  allow  the  patient  to  walk  upon 
the  under  surfaces  instead  of  the  ends  of  the  metatarsal  bones.  It 
should  not  be  so  great  as  to  obliterate  the  arch  of  the  foot  entirely,  and 
it  is  well  to  make  the  wedge  rather  small  in  the  first  place,  and  then,  if 


TALIPES  CALCANEUS  335 

necessary,  to  remove  a  second  slice,  the  thickness  of  which  can  be 
estimated  accurately  after  the  wedge  has  been  removed. 

The  bleeding  is  arrested,  the  wound  stitched  up  without  a  drainage 
tube,  antiseptic  dressings  applied,  and  the  foot  put  into  proper  position. 
A  back  splint  with  a  footpiece  at  right  angles  is  put  on  for  about  six 
weeks,  until  bony  union  has  occurred.  Then  the  tendo  Achillis  may  be 
divided,  and,  if  necessary,  the  posterior  ligaments  of  the  ankle  also  may 
be  cut,  so  as  to  enable  the  foot  to  be  brought  up  to  a  right  angle  in  the 
first  instance,  and,  subsequently,  to  an  acute  angle.  In  another  three 
weeks  the  patient  may  be  allowed  to  walk,  and  the  treatment  recom- 
mended for  the  milder  cases  of  talipes  equinus  is  then  carried  out  (see  p.  326). 

TALIPES  CALCANEUS. 

As  a  congenital  deformity  this  is  rare.  It  usually  occurs  as  the  result 
of  infantile  paralysis  of  the  calf  muscles  The  congenital  form  is  often 
associated  with  an  absence  of  the  fibula,  or  some  similar  arrest  of  develop- 
ment of  the  leg.  When  the  fibula  is  absent,  there  is  usually  talipes  cal- 
caneo-valgus.  Some  degree  of  talipes  calcaneus  is  often  seen  in  the 
newly-born  child,  but  it  rarely  requires  attention  and  nearly  always  recovers 
spontaneously.  In  the  paralytic  form,  the  front  part  of  the  foot  is  drawn 
up  by  the  unbalanced  action  of  the  muscles  on  the  front  of  the  leg  ;  the 
heel  is  depressed,  so  that  in  bad  cases  the  upper  part  of  the  instep  may 
lie  in  contact  with  the  anterior  surface  of  the  leg,  whilst  the  patient 
walks  upon  the  extreme  point  of  the  heel.  There  is  a  tendency  to  some 
valgus  deformity  as  well. 

TREATMENT. — As  in  all  the  other  paralytic  cases,  it  is  easy  to 
get  the  foot  in  position  without  using  force  as  long  as  the  affection  is  in  its 
early  stages  ;  in  these  cases  the  treatment  must  be  directed  to  retaining 
the  foot  in  proper  position,  whilst  efforts  are  made  to  maintain  or  restore 
the  functions  of  the  paralysed  muscles. 

By  Massage  and  Apparatus. — To  meet  the  first  indication,  a  suit- 
able splint  should  be  applied ;  in  children  we  prefer  the  simple  metal 
splint  with  the  connecting  stout  copper  wire,  already  described  (see 
Fig.  100),  which  can  be  applied  by  the  nurse.  The  splint  should  be  taken 
off  several  times  a  day  and  massage  should  be  applied  to  the  calf  muscles, 
followed  by  manipulations  designed  to  stretch  the  muscles  on  the  front 
of  the  leg.  The  Faradic  current  may  be  beneficial,  whilst  at  night,  and 
in  the  intervals  between  the  application  of  the  massage  and  galvanism, 
the  splint  should  be  re-applied.  If  these  measures  be  carefully  carried 
out  in  the  early  stages,  tenotomy  will  seldom  be  necessary. 

The  subsequent  treatment  will  depend  upon  the  condition  of  the 

muscles i.e.  the  extent  and  distribution  of  the  paralysis, — and  also  on 

the  willingness  of  the  parents  to  submit  the  child  to  operative  procedures. 
Thus  the  paralysis  of  the  calf  muscles  may  be  only  slight,  but  the  parents 


336 


DEFORMITIES 


may  be  averse  to  operation  ;  or  the  paralysis,  though  marked,  may  not 
be  complete.  On  the  other  hand  the  paralysis  of  the  calf  muscles  may  be 
complete.  This  method  is  also  admirably  suited  for  the  later  stages  of 
those  cases  in  which  the  paralysis  of  the  calf  muscles  is  only  partial  and 
there  is  good  hope  that  recovery  may  occur  provided  that  the  weak 
muscles  can  be  exercised  gradually  and  are  not  submitted  to  undue 
strain.  It  is,  moreover,  the  only  procedure  that  can  be  adopted  when 
operative  measures  are  refused  or  fail. 

As  the  child  learns  to  walk,  he  should  be  fitted  with  lateral  leg-irons 

grasping  the  limb  just  above  and 
below  the  knee,  and  fastened  below 
into  the  heel  of  the  boot.  There 
should  also  be  a  hinge-joint  opposite 
the  knee  and  the  ankle  ;  the  latter 
should  have  a  stop  so  as  to  prevent 
the  foot  being  bent  upwards  beyond 
a  right  angle,  and  it  is  well  also  to 
have  an  artificial  tendo  Achillis  fitted 
to  the  apparatus  (see  Fig.  109)  ;  the 
most  convenient  arrangement  is  a 
rubber  spring  from  the  heel  of  the 
boot  to  the  band  below  the  knee. 
When  the  foot  is  lifted  from  the 
ground,  the  heel  is  drawn  up  by  the 
spring,  and  when  the  foot  is  brought 
to  the  ground,  the  weight  of  the  body 
stretches  the  rubber  and  allows  the 
foot  to  come  to  a  right  angle,  where 
it  is  stopped  by  the  hinge  arrange- 
ment. When  the  patient  is  not 
walking,  it  is  well  to  take  off  this 
apparatus,  which  is  often  heavy  for 
an  enfeebled  limb,  and  to  employ 
massage,  electricity  and  douching, 
and  the  lighter  splint  already  mentioned  (vide  supra). 

By  shortening  the  Tendo  Achillis. — When  electrical  examination 
shows  that  there  is  still  some  healthy  muscular  tissue  left  in  the  calf 
muscles,  the  usefulness  of  the  limb  may  be  promoted  by  shortening 
the  tendo  Achillis.  The  operations  for  shortening  the  tendo  Achillis 
are  not  always  satisfactory,  as  the  union  between  the  divided  ends 
may  stretch  after  a  time  and  allow  the  deformity  to  be  reproduced. 
On  this  account  simple  transverse  division  and  resection  of  a  portion 
of  the  tendon  are  not  always  sufficient.  In  order  to  obtain  a  suc- 
cessful result,  the  operation  should  be  more  elaborate  and  designed  to 
obtain  a  broader  and  firmer  uniting  surface,  or  the  tendon  need  not 


FIG.  109. — BOOT  FOR  USE  IN  TALIPES  CAL- 
CANEUS.  The  india-rubber  spring  behind  takes 
the  place  of  the  faulty  calf  muscles.  The  boot  is 
often  fitted  with  a  stop  at  the  hinge  joint  opposite 
the  ankle  so  as  to  prevent  the  toes  being  raised 
unduly.  (Hoffa.) 


TALIPES  CALCANEUS  337 

be  divided  at  all,  but  its  point  of  insertion  into  the  os  calcis  may  be 
changed. 

Plastic  Operations  upon  the  Tendo  Aehillis.— The  tendo  Achillis  is 
exposed  by  turning  up  a  flap,  made  by  carrying  an  incision  from  a  point 
about  half  an  inch  to  one  side  of  the  tendon,  and  at  a  similar  distance 
above  the  proposed  point  of  division,  downwards,  to  an  inch  below  the 
proposed  point  of  division,  and  then  bringing  it  across  the  tendon,  and 
up  to  a  point  on  the  opposite  side  of  the  tendon  corresponding  to  its 
starting  point  (see  Fig.  no).  The  object  of  making  a  flap  in  order  to 
expose  the  tendon  is  that  the  line  of  union  of  the  flap  shall  not  correspond 
anywhere  to  the  line  of  division  of  the  tendon,  and  therefore  there  will  be 


FIG.  no. — FLAP  METHOD  OF 
EXPOSING  THE  TENDO  ACHILLIS. 
The  line  of  section  for  the  plastic 
operation  for  shortening  the  ten- 
don is  also  shown,  and  it  can  be 
seen  that  there  is  no  likelihood  of 
the  cicatrix  in  the  skin  becoming 
united  to  that  in  the  tendon. 


FIG.  in. — OBLIQUE  SECTION  FOR  SHORTENING  TENDONS. 
In  A  are  shown  the  incisions,  the  upper  one  aa.'  com- 
mencing just  below  the  muscular  fibres ;  the  portion 
aa'b'b  between  the  two  incisions  is  removed.  In  B  this 
has  been  done,  and  the  cut  surfaces  of  the  tendon  have 
been  sutured.  Enough  has  been  removed  to  raise  the  heel 
and  point  the  toes  somewhat. 


no  risk  of  adhesion  between  the  incision  in  the  tendon  and  that  in  the  skin. 
The  method  of  shortening  the  tendon  varies ;  there  are  two  principal 
plans :  to  divide  the  tendon  obliquely,  so  as  to  have  a  very  broad  surface 
for  union,  and  to  divide  it  in  a  Vshaped  manner.  Occasionally  it 
may  be  necessary  to  divide  the  tendons  on  the  front  of  the  ankle  as  a 
preliminary  measure  if  they  offer  any  obstacle  to  re-position  of  the  limb. 

Oblique  Section  of  the  Tendo  Achillis. — The  tendon  is  exposed  in  the 
manner  just  indicated,  and  then  divided  obliquely  from  above  down- 
wards and  forwards  (see  Fig.  in).  The  incision  through  the  tendon 
should  be  nearly  two  inches  in  length,  and  should  commence  close  to,  or 
even  actually  through,  some  of  the  muscular  fibres.  After  the  tendon 
has  been  divided,  a  sufficient  portion  of  the  lower  part  is  removed  by  a 
second  incision  parallel  to  the  first ;  the  amount  removed  should  be 
such  that,  when  the  oblique  surfaces  are  brought  into  apposition,  the 
foot  is  either  at  or  slightly  beyond  a  right  angle  to  the  leg.  The  foot  is 


338 


DEFORMITIES 


brought  into  position  and  the  cut  surfaces  of  the  tendon  are  united  by  a 
continuous  suture.  Haemorrhage  is  arrested,  and  the  wound  is  sewn  up 
without  a  drainage  tube.  A  broad  surface  for  union  is  thus  obtained, 
and  the  result  is  usually  fairly  satisfactory  if  care  be  taken  not  to  put  any 
tension  upon  the  tendon  for  some  weeks  afterwards. 

"[.-shaped  Section  of  the  Tendo  Achillis. — After  turning  up  a  flap  as 
before,  an  incision  is  made  in  the  tendon,  commencing  on  one  side,  and 
running  transversely  across  it  as  far  as  its  centre.  The  knife  is  then 
turned  downwards  at  a  right  angle  to  this  incision,  and  the  tendon  is 
split  vertically  along  the  middle  line  for  about  a  couple  of  inches.  At 
the  lower  end  of  this  incision  the  knife  is  turned  transversely  across  the 


B. 

FIG.  112. — T.-SHAPED  SECTION  FOR  SHORTENING  TENDONS.  In  A  the  tendon  is 
seen  exposed  by  raising  a  flap  ;  the  dark  line  shows  the  incision  in  the  tendon,  the  dotted 
ones  indicating  the  amount  of  tendon  removed  after  the  latter  has  been  thus  divided.  In 
B  the  tendon  has  been  shortened  and  sewn  together  ;  the  toes  are  a  little  depressed  as  in 
the  preceding  figure.  C  shows  diagrammatically  the  steps  of  the  division  of  the  tendon 
and  the  methods  of  suture.  In  (i)  the  line  of  incision  in  the  tendon  is  c,  a,  b,  d ;  when 
the  two  ends  are  separated,  incisions  along  the  dotted  lines  a'd'  and  6V  are  made  to  cut 
off  the  portions  acc'b'  and  d'a'bd  (shaded  in  the  diagram.)  This  gives  the  tendon  the 
shape  and  length  represented  in  (2).  The  divided  ends  are  then  brought  together  and 
sutured  as  in  (3).  It  is  important  to  remember  in  cutting  off  the  portions  of  tendon  that 
di  must  be  equal  in  length  to  cc": 

tendon,  and  directed  towards  the  opposite  side  to  that  originally  divided, 
and  is  made  to  divide  the  remaining  half  of  the  tendon  (see  Fig.  112). 
In  this  way,  two  flaps  of  tendon  are  made,  and  enough  is  cut  from 
each  flap  to  obtain  the  necessary  shortening  when  the  divided  surfaces 
are  brought  into  contact.  A  good  practical  rule  is  to  make  the  vertical 
part  of  the  incision  in  the  tendon  double  the  length  of  the  portion  that 
must  be  removed  in  order  to  bring  the  foot  into  position.  The  ends  are 
stitched  in  accurate  apposition  with  silk  ;  details  of  the  method  of  suture 
are  given  in  connection  with  the  affections  of  tendons.  In  some  ways, 
this  method  is  more  satisfactory  than  the  preceding  one,  as  the  union  is  a 
combination  of  a  transverse  with  a  vertical  one,  which  is  very  strong, 
whereas  in  the  other  the  union  is  oblique  and  may  yield.  Moreover,  the 
"L-shaped  division  can  be  practised  lower  down,  and  need  not  involve 
the  muscular  fibres. 

After-treatment. — Whichever  be  the  method  adopted,  the  foot  must  be 


TALIPES  CALCAXEUS 


339 


kept  in  a  position  of  equinus  for  at  least  six  or  eight  weeks,  so  as  to 
allow  of  sound  union  between  the  divided  ends ;  even  then  great  care 
must  be  taken  not  to  put  strain  on  it  for  fear  of  stretching  the  uniting 
material.  The  patient  should  not  walk  for  six  months  after  the  operation 
and,  when  walking  is  permitted,  should  be  furnished  with  the  apparatus 
fitted  with  a  stop  which  prevents  the  joint  being  dorsi-flexed  beyond  a 
right  angle  (see  p.  336).  The  calf  should  be  massaged  and  douched  daily, 
and  the  Faradic  current  applied  to  the  muscles. 

Transplantation  of  the  Insertion  of  the  Tendo  Aehillis.— In  order  to 
avoid  the  risk  of  the  union  of  a  divided  tendon  stretching  subsequently, 
some  surgeons  alter  the  bony  attachment  of  the  tendo  Aehillis  to  the  os 
calcis.  When  the  nutrition  of  the  leg  is  faulty,  and  when,  therefore,  the 
union  in  such  a  slightly  vascular  structure  as  tendon  might'  be  imperfect 
a  satisfactory  result  may  be 
obtained  by  altering  the 
point  of  insertion  of  the 
tendo  Aehillis  into  the  os 
calcis.  The  objection  to 
this  plan  is,  however,  that 
the  amount  of  shortening 
obtained  by  its  means  is 
comparatively  limited,  and 
the  method  is  only  of  real 
value  when  the  degree  of 
calcaneus  is  very  moderate. 

Two  operations  have 
been  recommended  (see  Fig. 
113) ;  in  the  first,  a  flap  with 
its  convexity  upwards  is 
raised  over  the  heel,  and  dis- 
sected downwards  so  as  to  expose  the  whole  of  the  posterior  part  of  the 
os  calcis.  A  saw  is  then  applied  transversely  to  the  upper  surface  of  the 
bone  immediately  in  front  of  the  tendon,  and,  by  a  vertical  cut,  a  thin  slice 
of  the  bone,  with  the  attachment  of  the  tendo  Aehillis  to  it,  is  sawn  off. 
This  slice  of  bone  is  pulled  down  until  the  insertion  of  the  tendon  is  as 
low  as  may  be  necessary,  or  as  low  as  possible,  and  the  bone  is  fixed  into 
its  new  position  by  two  or  three  small  tacks.  The  projecting  lower 
portion  of  the  slice  of  bone  is  then  cut  off  level  with  the  under  surface  of 
the  os  calcis. 

When  the  deformity  is  extreme,  it  has  been  advised  that  the  upper 
part  of  the  bone  thus  sawn  off  should  be  turned  round  at  a  right  angle 
and  applied  to  a  raw  surface  made  by  a  chisel  on  the  under  surface  of  the 
os  calcis ;  this  brings  down  the  insertion  of  the  tendon  to  the  lowest 
possible  point.  The  results  of  this  plan,  however,  do  not  seem  to  be  as 
satisfactory  as  those  of  the  preceding  one. 


FIG.  113. — TRANSPLANTATION  OF  THE  TENDO  ACHILLIS. 
This  is  a  diagrammatic  representation  of  the  two  operations 
described  in  the  text.  In  A  the  slice  of  the  os  calcis  is  drawn 
down  as  low  as  possible  and  fixed  in  position  with  screws  : 
the  portion  below  the  dotted  line  ab  is  then  sawn  off.  In  B 
further  shortening  is  obtained  by  turning  the  slice  of  bone 
round  at  right  angles,  making  a  raw  surface  with  a  chisel  or 
saw  on  the  under  aspect  of  the  os  calcis  and  fastening  the  slice 
of  bone  down  to  it. 


Z  2 


340  DEFORMITIES 

After-treatment. — After  the  operation  the  wound  is  stitched  up  without 
a  drainage  tube  and  the  foot  is  put  up  on  a  splint  with  the  toes  markedly 
pointed  for  about  six  weeks  until  bony  union  is  complete,  when  the 
patient  may  walk  about  wearing  the  boot  already  described  (see  p.  336). 

By  Muscle  and  Tendon  Transplantation. — This  subject  has 
attracted  considerable  attention,  and  may  well  be  considered  here,  since  it 
was  for  the  relief  of  a  case  of  paralytic  talipes  calcaneus  that  Nicoladoni 
performed  the  first  operation  of  the  kind  in  1882.  Since  that  time  the 
principle  has  been  applied  to  various  paralytic  deformities  with  enough 
success  to  warrant  the  procedure  taking  a  permanent  place  in  the  surgery 
of  paralysis. 

The  method  has  for  its  object  the  assumption  of  the  functions  of  a 
paralysed  muscle  by  a  neighbouring  healthy  one.  This  may  be  done 
either  by  the  attachment  of  the  tendon  of  a  paralysed  muscle  to  part  or 
the  whole  of  a  tendon  of  a  neighbouring  healthy  muscle  or  by  trans- 
planting the  insertion  of  a  healthy  muscle  to  the  insertion  of  a  paralysed 
one.  Thus,  in  the  case  of  talipes  calcaneus  the  tendo  Achillis  may  be 
attached  to  the  peroneus  longus  when  the  latter  muscle  is  not  paralysed, 
and  thereby  the  healthy  peroneus  is  made  to  assume  the  functions  of 
the  paralysed  calf-muscles.  The  peroneus  longus  might  also  be  trans- 
planted directly  into  the  os  calcis  if  desired.  The  rectification  of  the 
deformity  is  thus  effected  by  muscular  agency  and  not  by  splints. 

The  method  should  not  be  practised  until  it  is  certain  that  no  further 
recovery  of  function  will  occur  in  the  affected  muscle  or  group  of  muscles  ; 
therefore  at  least  two  years  should  be  allowed  to  elapse  between  the 
onset  of  the  paralysis  and  the  performance  of  the  operation,  for  extensive 
recovery  may  occur  under  suitable  conditions  even  in  the  most  unpromis- 
ing cases.  During  this  time  also  it  is  essential  that  the  limb  should  be 
in  such  a  position  as  to  relieve  the  paralysed  muscles  of  all  undue  strain. 

Asepsis  is  essential  for  success  ;  it  is  important  to  choose  muscles 
that  will  undergo  the  least  alteration  in  direction  in  the  process  of  trans- 
plantation. The  incision  must  be  so  arranged  that  the  line  of  union 
in  the  tendon  does  not  coincide  anywhere  with  that  in  the  skin.  The 
limb  should  be  put  up  so  that  there  is  no  strain  put  upon  the  union 
between  the  anastomosed  tendons  ;  finally  the  transplanted  muscle  has 
to  be  exercised  gradually  to  perform  its  new  functions  and  to  bear  the 
new  strains  thrown  upon  it.  Too  much  must  not  be  expected  from  this 
method  ;  when  properly  performed  in  suitable  cases,  however,  so  much 
improvement  may  follow  that  splints  or  special  apparatus  may  be  dis- 
pensed with. 

In  deciding  upon  the  particular  form  of  transplantation  that  he  will 
adopt,  the  surgeon  must  be  guided  by  the  extent  and  distribution  of  the 
paralysis,  but  he  should  always  try  to  work  with  muscles  whose  functions 
are  similar,  although  this  is  not  essential,  as  a  muscle  can  be  re-educated 
and  extensors  can  quite  well  become  flexors.  He  should  never  transplant 


TALIPES  CALCANEUS  34I 

a  muscle  or  its  tendon  into  such  a  situation  that  it  cannot  work  to  ad- 
vantage, and  finally  he  should  not  set  one  muscle  the  task  of  performing 
two  opposite  movements  as  would  be  the  case  if  the  tendo  Achillis  were 
split  and  one  half  were  anastomosed  to  a  paralysed  tibialis  anticus. 

The  choice  of  operations  is  very  large  :  we  need  only  indicate  the  most 
common  ones,  as  each  case  must  be  treated  on  its  merits.  When  the 
dorsal  abductors  are  paralysed  and  the  foot  falls  into  a  varus  position, 
the  tendon  of  the  tibialis  anticus  may  be  made  to  pass  beneath  the  ex- 
tensors and  fastened  to  the  insertion  of  the  peroneus  tertius.  A  paralysed 
tibialis  anticus  may  be  replaced  by  a  healthy  extensor  hallucis,  and 
paralysis  of  the  calf  muscles  may  be  treated  by  inserting  the  tendon  of 
the  peroneus  longus  into  the  tendo  Achillis.  Sometimes  the  tendon  oi 
the  peroneus  brevis  is  made  to  pass  between  the  tendo  Achillis  and  the 
tibia  to  be  inserted  into  the  tendon  of  the  tibialis  posticus. 

There  is  little  to  say  as  to  the  steps  of  the  operation  ;  tendon  grafting 
is  dealt  with  elsewhere  (see  Vol.  II.).  The  main  points  to  be  attended 
to  are : 

(1)  To  unite  the  tendons  so  that  there  is  no  slack  when  the  limb  is 
in  the  over-corrected  position. 

(2)  To  secure  as  firm  and  as  large  a  surface  of  union  as  possible,  by 
an  oblique  section,  or  by  some  of  the  other  methods  recommended  for 
tendon  suture.     When  the  tendon  of  the  paralysed  muscle  is  very  small 
it  is  well  to  implant  the  tendon  of  the  healthy  one  into  or  beneath  the 
periosteum  ;    some  surgeons  bore  holes  in  the  bone  and  thus  tie  down 
the  tendon.     These   precautions   are  necessary  to   prevent  the  union 
stretching  or  giving  way  subsequently,  as  it  might  do  were  an  ordinary 
end-to-end  union  practised. 

(3)  Sometimes  a  single  large  incision  will  do,  e.g.  when  two  parallel 
muscles  are  operated  upon  ;  sometimes  a  flap  is  necessary  and  sometimes 
two  separate  incisions  are  wanted,  e.g.  when  a  tendon  has  to  be  trans- 
planted from  one  side  of  the  foot  to  the  other.     The  mobility  of  the 
tendon  does  not  appear  to  be  materially  interfered  with,  even  after  it 
has  been  removed  from  its  sheath  and  passed  for  a  considerable  distance 
through  connective  tissue,  so  long  as  its  direction  is  such  that  it  can  act 
to  advantage. 

(4)  After  the  operation,  the  limb  is  put  up  in  the  slightly  over- 
corrected  position,  and  when  the  wound  has  healed,  a  plaster  casing  is 
applied  and  left  on  for  a  month  or  more  in  order  to  insure  firm  union. 
Some  light  apparatus  designed  to  prevent  stretching  of  the  transplanted 
muscle  should  be  worn  for  at  least  another  six  months,  and  during  this  time 
massage  and  exercises  must  be  employed  to  strengthen  the  transplanted 
muscle.     In  seven  or  eight  months  from  the  time  of  operation  all  apparatus 
may  be  dispensed  with,  and  the  patient  may  walk  freely.     It  is  advisable, 
however,  to  persevere  with  the  exercises  for  at  least  six  months  longer. 

Arthrodesis.— This  term  implies  the  artificial  production  of  anchylosis 


342  DEFORMITIES 

in  a  joint  by  removing  the  articular  cartilage.  It  is  useful  in  those 
flail-like  conditions  of  the  ankle-joint  when  all  the  muscles  in  connection 
with  it  are  paralysed,  as  the  patient  is  thereby  enabled  to  bear  his 
weight  firmly  upon  the  foot,  whereas  otherwise  no  apparatus  would 
fix  the  joint  without  causing  serious  pressure  sores.  It  is  done  at  the 
knee  joint  in  some  cases  in  which  the  paralysis  is  so  wide-spread  that  the 
joint  is  flail-like  ;  it  then  gives  the  patient  a  firm  support  in  place  of  a  limb 
that  is  too  feeble  to  bear  apparatus.  It  is  also  useful  in  the  case  of  the 
astragalo-scaphoid  joint  in  bad  cases  of  valgus. 

The  steps  of  the  operation  need  not  be  described  in  detail  here. 
The  particular  joint  is  opened  freely  by  a  suitable  incision  and  all  the 
articular  cartilage  is  removed  by  a  gouge  or  a  sharp  cutting  rugine.  The 
wound  is  then  closed  and  the  limb  is  put  up  in  the  required  position  and 
kept  there  for  six  weeks  or  more,  when  firm  union  should  have  occurred 
between  the  articular  surfaces.  It  is  important  to  remove  the  cartilage 
freely. 

TALIPES  VALGUS. 

As  a  congenital  affection,  this  condition  is  comparatively  rare  ;  when 
it  does  occur  it  is  most  frequently  associated  with  absence  of  the  fibula. 
Even  as  an  acquired  affection  the  deformity  is  not  very  common  ;  it 
then  most  frequently  results  from  infantile  paralysis,  and  the  deformity 
is  produced  by  the  unbalanced  action  of  the  peronei  muscles,  the  tibials 
and  the  extensors  of  the  foot  being  paralysed.  It  may  also  occur  in 
connection  with  rickety  deformities  of  the  leg,  or  faulty  union  of 
fractures  of  the  tibia. 

PATHOLOGICAL  CHANGES.— The  principal  alterations  in 
the  foot  are  stretching  of  the  internal  lateral  ligament  of  the  ankle  joint 
with  a  corresponding  contraction  of  the  external  lateral  ligament,  and 
to  a  lesser  degree,  stretching  of  some  of  the  other  ligaments  on  the  inner 
side  of  the  foot.  In  the  early  stage  it  is  easy  to  bring  the  foot  into  its 
normal  position  by  manipulations  alone,  but  in  the  later  stages  the 
ligaments  and  muscles,  especially  the  peronei,  become  contracted,  and 
will  require  division  before  the  foot  can  be  restored  to  position.  In 
severe  or  long-standing  cases,  alteration  in  the  shape  of  the  bones  also 
occurs,  and  forms  a  further  obstacle  to  the  reduction  of  the  deformity. 

TREATMENT. — In  the  early  cases,  in  which  the  position  of  the 
foot  can  be  rectified  by  the  hand  alone,  the  treatment  should  aim  at 
preventing  the  occurrence  of  the  deformity,  and  increasing  the  strength 
of  the  weakened  muscles,  so  as  to  enable  them  to  raise  the  inner  border 
of  the  foot.  This  should  be  done  by  manipulations  carried  out  by  the 
nurse,  who  gradually  inverts  the  foot,  and  brings  it  inwards  at  the  mid- 
tarsal  joint ;  massage  and  douching  of  the  muscles,  particularly  the 
tibials  and  extensors  of  the  toes,  and  the  galvanic  current  are  also  useful. 


TALIPES  VALGUS 


343 


In  the  intervals  between  the  massage  and  passive  movements,  the  foot 
should  be  kept  in  the  corrected  position  by  means  of  a  suitable  apparatus. 
In  the  early  stage,  before  the  patient  learns  to  walk,  the  metal  splint 
already  mentioned  (see  p.  316)  is  the  most  satisfactory,  but  when  the 
patient  can  walk  he  should  wear  an  apparatus  designed  to  prevent  eversion 
of  the  foot.  This  consists  of  lateral  leg  irons,  the  outside  one  being 
particularly  strong,  jointed  at  the  ankle,  and  hinged  to  the  heel  of  the 
boot,  which  should  be  of  thick  leather,  and  should  have  the  inner  side 
of  the  sole  and  heel  slightly  thicker  than  the  outer  (see  Fig.  114).  The 
heel  should  also  extend  further  forwards  than 
usual ;  in  fact,  the  boot  should  be  made 
much  on  the  lines  recommended  for  flat  foot 
(see  p.  306) ,  for  in  these  cases  of  talipes  valgus 
a  certain  amount  of  flat  foot  is  generally 
present,  and  must  be  corrected.  In  many 
cases  it  is  well  also  to  employ  Whitman's 
springs  (see  p.  303).  The  boot  should  only 
be  worn  while  walking,  and  should  be  re- 
moved as  soon  as  the  patient  complains  of 
being  tired,  or  of  the  apparatus  causing 
pain  ;  the  limb  should  then  be  massaged 
and  douched,  and  the  light  metal  splint 
put  on. 

When  the  tibialis  posticus  is  completely 
paralysed,  its  tendon  may  be  joined  either  to 
that  of  the  peroneus  longus  or  to  a  slip 
divided  from  the  tendo  Achillis  (see  p. 
341),  and  thus  the  support  to  the  inner 
border  and  arch  of  the  foot  may  be 
strengthened. 

In  advanced  cases  in  which  there  is  marked  shortening  of  the  peronei 
tendons,  it  may  be  necessary  to  divide  them  and  sometimes  also  to  divide 
the  external  lateral  ligament  of  the  ankle  joint.  Division  of  the  peronei 
tendons  is  done  about  an  inch  and  a  half  above  the  tip  of  the  external 
malleolus.  The  tenotomy  knife  is  inserted  between  the  tendons  and  the 
fibula  ;  the  edge  of  the  peroneus  longus  can  be  made  out  easily,  and  the 
peroneus  brevis  conies  into  relief  as  soon  as  this  is  divided,  and  can  also 
be  cut.  The  short  saphena  vein  may  be  wounded  in  this  operation  but 
this  is  not  a  matter  of  consequence.  In  paralytic  cases,  instead  of  merely 
dividing  the  peronei  it  is  well  to  join  the  divided  peroneus  longus  to  the 
tibialis  posticus  (vide  supra). 

After  the  tendons  have  been  cut,  the  foot  should  be  put  up  in  a  position 
of  slight  adduction.  In  hospital  patients  it  is  best  to  put  up  the  foot  in 
plaster  of  Paris.  Any  co-existing  flat  foot  must  also  be  corrected  and 
the  arch  of  the  instep  well  raised. 


FIG.  114.  —  BOOT  FOR  USE  IN 
TALIPES  VALGUS.  These  are  similar 
to  those  for  use  in  flat  foot,  with  the 
addition  of  lateral  leg-irons,  the  outer 
one  being  especially  stout. 

The  drawing  is  a  view  of  the  boot 
from  the  inner  side,  and  shows  the 
obliquity  of  the  heel  and  the  filling  up 
of  the  arch  of  the  instep.  Compare 
Fig.  96. 


344  DEFORMITIES 

When  there  is  sufficient  union  between  the  divided  ends  of  the  tendons, 
namely,  after  the  lapse  of  about  three  weeks,  treatment  on  the  lines 
already  laid  down  for  the  milder  degrees  of  the  deformity  should  be 
carried  out  (vide  supra).  In  the  case  of  a  child  not  able  to  walk,  massage 
of  the  weak  muscles,  with  proper  manipulations  and  fixation  of  the  foot 
by  splints  in  the  intervals,  should  be  employed  ;  when  the  child  can  walk, 
the  apparatus  above  recommended  should  be  used  in  addition  to  massage 
and  electricity. 

When  the  deformity  is  associated  with  some  alteration  of  the  bones, 
resulting  either  from  rickets  or  from  injury,  the  initial  treatment  must  be 
directed  to  remedying  the  osseous  deformity.  Thus,  in  rickety  cases 
the  bones  of  the  leg  should  be  brought  straight  (see  Curved  Tibiae)  should 
the  deformity  be  extreme.  In  traumatic  valgus  occurring  after  Pott's 
fracture,  it  may  be  necessary  to  restore  the  bones  of  the  leg  to  their 
proper  position.  This  matter  is  discussed  in  connection  with  Pott's 
fracture  (see  Vol.  II.).  The  results  of  this  operation  are  often  very 
successful. 

TALIPES  EQUINO-VALGUS. 

It  is  not  uncommon  for  some  equinus  to  be  combined  with  talipes 
valgus.  This  deformity  is  perhaps  more  frequently  congenital  than 
acquired.  The  remarks  about  equino-varus  may  be  applied  equally  to 
talipes  equino-valgus.  As  in  the  treatment  of  equino-varus,  the  valgus 
deformity  should  be  corrected  before  the  tendo  Achillis  is  divided. 

TALIPES   VARUS. 

Pure  talipes  varus  is  exceedingly  rare,  the  great  majority  of  the  cases 
being  the  condition  spoken  of  as  talipes  equino-varus.  True  varus, 
however,  may  result  from  infantile  paralysis,  affecting  only  the  peronei 
muscles  and  leaving  the  tibials  and  the  anterior  muscles  of  the  leg  un- 
affected. It  may  also  result  from  cicatricial  contraction,  or  from  badly 
united  fractures  of  the  leg.  The  treatment  of  this  affection  is  similar  to 
that  of  the  varus  deformity  in  talipes  equino-varus. 

TALIPES   EQUINO-VARUS 

This  form  of  club-foot  is  the  most  common  and  the  most  important 
of  all  those  with  which  the  surgeon  has  to  deal.  The  foot  is  in  a  position 
of  adduction,  the  inner  side  being  shortened  and  drawn  up,  whilst  there 
is  a  marked  lateral  flexion  at  the  mid-tarsal  joint,  the  anterior  part  of 
the  foot  being  drawn  inwards.  Sometimes  the  displacement  of  the  front 
of  the  foot  is  so  marked  that  its  inner  border  forms  an  acute  angle  at 
the  mid-tarsal  joint.  Besides  this  deformity  the  heel  is  drawn  up  as  the 
result  of  the  shortening  of  the  calf  muscles.  The  vertical  plane  of  the 
whole  of  the  foot  is  altered,  the  under  surface  of  the  os  calcis  looking 
somewhat  inwards  instead  of  directly  downwards 


TALIPES  EQUINO-VARUS  345 

PATHOLOGICAL  CHANGES.— The  condition  may  be  con- 
genital or  acquired.  The  acquired  form  may  be  due  to  infantile  paralysis  ; 
to  some  spastic  condition  of  the  muscles,  as  in  spastic  paraplegia  or 
hysteria  ;  to  injuries,  such  as  dislocations  or  fractures  about  the  ankle 
joint ;  to  diseases  of  that  articulation  ;  or  to  cicatricial  contraction  in 
its  neighbourhood.  In  the  congenital  form  there  is  not  only  tightness  of 
certain  tendons,  but  also  alterations  in  the  other  structures  of  the  foot, 
particularly  the  ligaments  and  bones.  The  most  marked  change  in  the 
bones  occurs  at  the  junction  of  the  neck  with  the  body  of  the  astragalus, 
the  normal  angle  of  which  is  profoundly  altered ;  according  to  Parker, 
instead  of  being  about  38°  as  in  the  normal  foetal  astragalus,  it  may 
reach  as  much  as  50°.  Under  normal  conditions  the  obliquity  of  the 
neck  of  the  astragalus  diminishes  as  the  child  grows,  so  that  the  angle  of 
inward  deflection  of  the  neck  is  a  little  over  10°  in  the  adult ;  on  the 
other  hand,  in  equino-varus  in  the  adult,  it  may  still  remain  at  about 
50°.  It  is  evident  that  the  shape  of  the  anterior  part  of  the  foot  must  be 
seriously  altered  by  such  a  marked  increase  in  this  angle,  and  that  there 
is  a  distinct  obstacle  to  the  reduction  of  the  deformity  in  the  osseous 
system  itself. 

As  the  result  of  the  equinus  position  there  is  a  further  change  in  the 
astragalus.  The  greater  part  of  the  upper  articular  surface  of  the  bone 
is  uncovered,  and  the  alterations  described  in  speaking  of  talipes  equinus 
occur  as  the  result  (see  p.  320)  ;  at  the  same  time,  the  portion  which 
articulates  with  the  tibio-fibular  arch  is  narrower  than  it  ought  to 
be,  and  thus  a  certain  amount  of  lateral  displacement  is  allowed.  As 
time  goes  on,  changes  also  occur  in  the  other  tarsal  bones,  particularly 
the  cuboid  and  scaphoid,  but,  although  these  may  give  rise  to  an  additional 
obstacle  to  the  reduction  of  the  deformity,  their  influence  is  not  nearly 
so  great  as  that  of  the  deformity  in  the  astragalus.  In  advanced  cases 
there  is  also  a  marked  alteration  in  the  bones  of  the  leg,  the  ankle  being 
rotated  inwards  as  a  whole,  so  that  the  external  malleolus  lies  on  a  plane 
anterior  to  that  of  the  internal,  this  condition  being  the  opposite  of  the 
normal.  These  extreme  changes  are  usually  only  reached,  however, 
when  the  patient  is  allowed  to  attain  adult  life  before  an  attempt  is  made 
to  restore  the  foot  to  its  proper  position. 

Besides  the  alterations  in  the  bones  there  are  also  certain  changes  in 
the  ligaments  of  the  tarsus  ;  those  on  the  dorsum  and  the  outer  surface  of 
the  foot  become  elongated,  while  those  on  the  inner  side  are  shortened 
and  thickened.  According  to  Parker  the  most  important  changes  take 
place  in  the  ligaments  around  the  astragalo-scaphoid  joint,  in  the  anterior 
portion  of  the  internal  lateral  ligament  of  the  ankle  joint,  and  in  the 
inferior  calcaneo-astragaloid  ligaments.  In  the  early  stages  of  the 
deformity  these  ligaments  interfere  more  seriously  with  its  reduction  than 
does  the  altered  shape  of  the  neck  of  the  astragalus  itself,  for  in  infants 
in  whom  the  bones  are  cartilaginous,  it  is  comparatively  easy  to  bend 


346  DEFORMITIES 

them  into  a  new  position,  whilst  the  ligaments  are  tight  and  thickened, 
and  are  not  stretched  so  readily. 

The  muscles  are  not  contracted  in  the  early  stages,  and  there  is  usually 
little  difficulty  in  reducing  the  deformity  in  an  infant  a  few  weeks  old  ;  if, 
however,  the  deformity  be  allowed  to  continue,  they  become  tight,  and 
reposition  of  the  foot  cannot  be  carried  out  until  after  division  of  their 
tendons.  The  muscles  chiefly  affected  are  the  tibialis  anticus  and  posti- 
cus,  the  gastrocnemius,  and  in  some  cases  1he  flexor  longus  digitorum. 

TREATMENT. — The  surgeon  has  to  take  into  consideration  the 
alterations  in  the  bones,  ligaments  and  muscles  ;  the  shortening  of  the 
plantar  fascia ;  and  finally,  the  tightness  of  the  skin  upon  the  inner 
border  of  the  foot.  The  contraction  of  the  plantar  fascia  and  the  tight- 
ness of  the  skin  are  points  of  special  importance,  for  the  shortening  of  the 
inner  border  of  the  foot  and  the  increase  of  the  plantar  arch  will  not  be 
remedied  unless  means  be  taken  to  rectify  these.  In  advanced  cases  also, 
changes  occur  from  pressure  upon  parts  that  are  not  intended  to  bear 
pressure.  Thus,  callosities  develop  on  the  outer  border  of  the  foot,  and, 
in  severe  cases,  on  the  outer  side  of  the  dorsum.  Beneath  the  callosities 
are  bursae,  which  are  liable  to  attacks  of  inflammation  and  suppuration 
and  may  cause  considerable  pain  and  give  rise  to  further  thickening  and 
matting  together  of  the  soft  parts  in  their  neighbourhood. 

From  the  point  of  view  of  treatment,  the  cases  of  equino-varus  coming 
under  the  notice  of  the  surgeon  may  be  divided  into  two  main  groups  : 
those  in  which  the  deformity  can  be  reduced  readily  by  manipulation, 
viz.,  those  in  which  there  are  no  resisting  structures  requiring  division  ; 
and  those  in  which  there  are  one  or  more  resisting  structures,  and  in 
which,  therefore,  some  form  of  operative  procedure  is  required  to  restore 
the  foot  to  position.  This  second  group  may  be  further  sub-divided  into 
two  classes,  namely  those  in  which  the  obstacle  to  reduction  is  formed 
by  shortened  muscles,  fasciae,  or  ligaments,  and  those  in  which  the 
obstacle  is  due  essentially  to  some  permanent  alteration  in  the  shape  of 
the  bones. 

Treatment  of  Cases  in  which  the  Deformity  can  be  reduced 
by  Manipulation  alone. — It  is  mainly  the  congenital  cases  seen  within 
the  first  few  weeks  after  birth  which  come  under  this  heading ;  in  them 
the  deformity  may  be  cured  without  the  necessity  for  any  operative 
procedure  if  careful  treatment  be  begun  at  once  and  carried  out  per- 
severingly.  In  this  early  stage  the  deformity  is  due  to  weakness  of  the 
muscles  and  to  alterations  in  the  shape  of  the  bones.  The  treatment, 
therefore,  should  consist  of  manipulations  designed  to  prevent  shortening 
of  the  muscles,  and  to  stretch  any  structures  that  are  unduly  tight ; 
besides  this,  some  form  of  retentive  apparatus  will  be  required  to  keep  the 
foot  in  position  in  the  intervals  between  the  manipulations.  Both  these 
measures  tend  to  restore  the  bones  gradually  to  their  proper  shape. 
Massage,  and,  in  some  cases,  electricity  should  also  be  employed  to 


TALIPES  EQUINO-VARUS  347 

increase  the  nutrition  of  the  muscles  ;  massage  is  more  useful  than 
electricity,  which  is  only  useful  when  the  case  is  of  paralytic  origin  and 
which  has  the  objection  that  it  may  frighten  the  child.  Unless  this  treat- 
ment be  begun  at  the  earliest  possible  period,  operative  measures  must 
precede  it,  since  tight  structures  will  have  to  be  divided.  Hence  treat- 
ment should  be  commenced  immediately  the  condition  is  noticed,  which 
is  usually  within  a  few  days  after  birth.  Under  these  circumstances,  the 
outlook  is  very  favourable,  and  practically  the  entire  course  of  treatment 
can  be  carried  out  by  the  mother  or  an  intelligent  nurse. 

Manipulations. — The  manipulations  are  simple,  but  should  be  carried 
out  regularly  and  for  a  long  time.  They  consist  essentially  in  abduction 
of  the  anterior  part  of  the  foot  at  the  medio-tarsal  joint,  and  eversion 
and  dorsi-flexion  of  the  foot  as  a  whole.  They  should  be  carried  out 
gently,  so  as  not  to  frighten  the  child  or  to  produce  pain ;  if  pain 
be  caused,  spasm  of  the  muscles  is  set  up,  and  this  offers  an  obstacle  to 
the  manipulations.  If,  on  the  other  hand,  the  manipulations  be  carried 
out  gently  and  in  a  coaxing  manner,  the  child  becomes  accustomed  to 
them  and  does  not  resent  them. 

The  front  part  of  the  foot  should  be  grasped  with  the  right  hand 
while  the  leg  is  steadied  with  the  left  which  embraces  it  just  above  the 
ankle  joint.  The  metatarsus  is  then  gradually  carried  outwards,  until  the 
inner  border  of  the  foot  is  quite  straight.  The  right  hand  should  next  be 
slipped  up  a  little  more  towards  the  heel,  so  as  to  grasp  the  whole  foot, 
the  toes  lying  between  the  bah1  of  the  thumb  and  the  little  finger.  The 
entire  foot  is  then  gradually  everted  until  the  sole  looks  rather  outwards, 
and  the  foot  is  dorsi-flexed  at  the  ankle  joint,  while  eversion  is  maintained. 
The  essential  points  in  this  procedure  are  to  unfold  the  anterior  part  of 
the  foot,  to  overcome  the  inversion  of  the  foot  as  a  whole,  and  to  dorsi-flex 
the  foot  at  the  ankle  joint.  It  is  of  extreme  importance  to  remember  that  it 
is  not  enough  to  produce  eversion  of  the  anterior  half  of  the  foot  alone — 
that  part,  namely,  in  front  of  the  mid-tarsal  joint.  This  point  is  often 
overlooked,  not  only  in  these  early  cases,  but  in  those  of  every  descrip- 
tion, and  the  result  is  that,  while  after  prolonged  treatment  the  equinus 
and  the  faulty  position  of  the  front  half  of  the  foot  have  been  overcome, 
the  under  surface  of  the  os  calcis  looks  inwards  instead  of  directly  down- 
wards. When  the  foot  is  everted,  the  os  calcis  should  be  everted  as  well 
as  the  anterior  part  of  the  foot. 

After  the  foot  has  been  brought  into  position  by  these  manipulations, 
it  should  be  held  there  with  the  right  hand  for  five  or  ten  minutes,  whilst 
the  leg  is  gently  rubbed,  and  the  muscles  of  the  calf  and  front  of  the  leg 
are  kneaded  with  the  left.  These  manipulations  and  the  accompanying 
massage  should  be  repeated  three  or  four  times  a  day,  and  in  the 
intervals  the  foot  should  be  fixed  in  a  splint,  so  as  to  prevent  recurrence 
of  the  deformity. 

Apparatus. — The  most  satisfactory  splint  for  infants  is  the  metal  one 


348  DEFORMITIES 

already  described  (see  Fig.  100)  which  should  be  firmly  fastened  on  the 
limb  with  bandages  while  the  foot  is  in  its  faulty  position  ;  then  one  portion 
of  the  splint  is  grasped  with  each  hand,  and  the  foot  is  slowly  brought  into 
a  position  of  eversion  and  dorsi-flexion,  i.e.  over-correction.  The  copper 
bar  yields  to  the  pressure  of  the  hand  but  is  stout  enough  to  prevent 
recurrence  of  the  deformity  from  muscular  action.  The  splint  should  be 
worn  continuously  night  and  day,  and  should  only  be  removed  to  allow 
of  the  manipulations  and  massage  already  described. 

At  the  end  of  three  or  four  months  from  the  commencement  of  treat- 
ment carried  out  methodically  in  this  manner,  the  foot  will  retain  its 
position,  even  if  the  splint  be  left  off  for  some  little  time ;  the  splint 
however,  should  be  continued  for  at  least  two  or  three  years  after  the 
deformity  has  been  corrected.  It  must  be  remembered  that,  although  the 
resistance  of  the  muscles  and  the  ligaments  may  be  overcome  quickly, 
it  takes  a  long  time  for  the  bones  which  are  altered  in  direction  to  be 
moulded  to  their  new  position,  so  that,  if  the  retentive  apparatus  be  left 
off  too  soon,  the  deformity  is  almost  certain  to  recur.  When  the  child 
begins  to  walk,  a  Scarpa's  shoe  (see  p.  354)  will  be  more  convenient  and 
satisfactory  than  the  arrangement  just  described. 

So  far,  we  have  been  speaking  only  of  cases  for  which  an  intelligent 
nurse  can  be  obtained,  who  can  give  the  child  constant  attention, — 
conditions  which  do  not  exist  among  the  poor.  When  there  is  difficulty 
in  obtaining  proper  attendance,  or  when  the  parents  are  too  stupid  to 
carry  out  the  treatment  properly,  the  best  procedure  is  to  put  the  foot 
up  in  plaster  of  Paris  in  the  over-corrected  position  quite  early.  This 
is,  however,  not  so  good  a  method  as  the  one  recommended  above,  as 
the  plaster  of  Paris  encloses  the  leg,  and,  therefore,  the  nutrition  of  the 
muscles  is  interfered  with  to  some  extent.  The  plaster  also  gets  soiled 
by  urine,  and  gets  loose,  and  the  skin  beneath  becomes  irritated  and  often 
ulcerated.  In  addition  to  these  drawbacks,  the  foot  of  an  infant  is  so 
small  and  yielding  that  it  is  very  difficult  to  get  a  proper  purchase  upon 
it.  If  plaster  of  Paris  be  employed,  it  should  be  renewed  at  least  once  a 
week,  and  great  care  must  be  taken  that  the  foot  is  held  in  the  over-cor- 
rected position  whilst  the  plaster  is  setting.  This  is  difficult  to  do  when  the 
foot  is  held  in  position  by  the  hands,  because  the  bony  points  that  have 
to  be  grasped  in  order  to  keep  the  foot  in  good  position,  are  just  those  on 
which  it  is  necessary  that  the  plaster  should  get  a  good  grip,  and  when  the 
hand  is  removed,  these  parts  are  unsupported,  and  must  be  covered 
subsequently. 

In  order  to  avoid  this  difficulty  the  best  plan,  in  our  opinion,  is  to 
put  the  foot  up  first  upon  a  splint  (preferably  Sayre's  apparatus),  and 
then  to  encase  the  whole  arrangement  in  plaster  of  Paris.  The  foot  and 
leg,  as  high  as  the  knee  are  dusted  with  boric  powder,  and  a  woollen  stocking 
is  drawn  over  them.  A  piece  of  wood  of  suitable  thickness,  which  may  be 
cut  from  a  cigar-box  for  a  young  child,  is  shaped  to  the  sole  of  the 


TALIPES  EQUINO-VARUS 


349 


foot,  but  made  to  extend  about  three  inches  beyond  the  toes  (see  Fig.  115). 
To  this  a  long  piece  of  strapping  is  attached  in  a  manner  similar  to  that 
described  for  talipes  equinus ;  viz.,  the  strapping  begins  on  the  upper 
surface  of  the  splint  in  front,  runs  backwards  round  its  posterior  edge, 
then  forwards  along  its  under  surface  and  around  the  anterior  border. 
From  this  point  the  strapping  must  be  long  enough  to  reach  rather  more 
than  half-way  up  the  thigh.  The  strapping  overcomes  the  equinus 
deformity,  but  a  second  piece  should  be  added  to  the  splint  so  as  to  pro- 
duce e version  of  the  foot.  This  is  attached  to  its  outer  border,  immedi- 
ately opposite  the  instep,  carried  transversely  over  the  upper  surface  of 
the  splint,  around  the  inner  border,  then  across  the  under  surface  to 
the  outer  border,  and  thence  up  to  the  middle  of  the  thigh.  The  splint, 
padded  with  boric  lint,  is  then  applied  to  the  sole,  and  a  broad  piece  of 


FIG.  115. — SAYRE'S  APPARATUS  FOR  KQUINO-VARUS.  This  is  identical  with  that 
shown  in  Fig.  104,  except  that  here  there  is  the  addition  of  the  long  outside  strip  of 
strapping  designed  to  produce  a  certain  amount  of  aversion  of  the  foot. 

strapping  is  carried  sandal-wise  around  its  posterior  end  and  over  the 
instep  to  prevent  it  slipping  backwards,  whilst  the  rest  of  the  foot  is  fixed 
on  the  splint  with  a  bandage.  The  foot  can  be  flexed  and  everted  by 
traction  upon  the  free  ends  of  the  two  pieces  of  strapping,  which  are  pulled 
taut  on  the  front  and  outer  sides  of  the  thigh  respectively,  and  a  bandage 
is  applied  around  the  limb  outside  them.  The  redundant  ends  of  the 
strapping  are  turned  down  over  the  upper  edge  of  the  bandage,  and 
covered  in  by  a  few  turns  carried  from  above  downwards,  Thus  the 
strapping  and  the  bandage  are  firmly  fixed  to  the  thigh,  and  the  foot  is 
retained  in  the  corrected  position.  A  plaster  of  Paris  bandage  is  then 
applied  to  the  foot  and  leg,  and  the  strapping  may  be  cut  through  above 
and  below  the  casing  when  this  has  properly  set ;  the  foot  is  thus  kept  in 
position  whilst  the  plaster  of  Paris  is  applied,  without  the  necessity  of 
holding  it  by  the  hand.  Each  time  the  plaster  casing  is  renewed  the  leg 
should  be  rubbed  and  the  foot  manipulated  (see  p.  347). 

When  the  child  is  old  enough  to  walk,  it  is  better  to  substitute  some 
form  of  apparatus  for  the  plaster  of  Paris,  and  for  poor  patients  the  most 


350  DEFORMITIES 

suitable  arrangement  probably  is  Sayre's  apparatus  (vide  supra)  without 
the  plaster  of  Paris.  When  walking  on  the  flat  piece  of  wood  the  child 
tends  to  evert  the  foot  more  and  more,  whilst  the  extra  length  of  the 
splint  corrects  the  equinus  fully.  The  chief  objection  to  the  apparatus 
is  that  it  requires  renewal  every  week,  and,  therefore,  after  a  few  weeks 
it  is  better  to  fit  the  child  with  some  light  form  of  apparatus  (see  p.  353) 
which  allows  him  to  walk  freely.  This  is  all  the  more  essential  as  there 
is  often  some  inward  rotation  of  the  leg  remaining  after  the  talipes  is 
cured  and  this  may  necessitate  the  use  of  lateral  leg-irons  fastened  above  to 
a  pelvic  band  and  so  arranged  as  to  prevent  any  inward  rotation.  An 
apparatus  of  this  kind  may  have  to  be  worn  for  several  years. 

In  the  second  group  of  cases  there  are  tight  structures 
such  as  tendons,  fascia,  or  ligaments,  which  oppose  the  re-position  of  the 
foot,  and  these  must  be  divided  in  the  first  place.  The  tendons  chiefly 
concerned  are  the  tendo  Achillis  and  those  of  the  tibiales,  whilst  the 
plantar  fascia  and  the  ligaments  around  the  astragalo-scaphoid  joint, 
and  in  some  cases  part  or  almost  the  whole  of  the  internal  lateral  ligament 
of  the  ankle  joint  may  require  division. 

Although  all  these  structures  may  have  to  be  divided  before  the  foot 
can  be  got  into  position,  it  is  advisable  to  carry  out  the  rectification  in 
two  stages ;  in  the  first,  the  varus  deformity  is  rectified  whilst  the  equinus 
is  left  uncorrected ;  division  of  the  tendo  Achillis  may  be  undertaken 
when  the  cure  of  the  varus  has  been  effected.  This  is  a  matter  of  import- 
ance, because  the  tendo  Achilhs  is  of  great  value  as  forming  a  point 
d'appui,  which  fixes  the  posterior  half  of  the  foot  and  permits  the  proper 
unfolding  of  the  anterior  part.  If  the  tendo  Achillis  be  divided  at  the 
same  time  as  the  other  structures,  there  will  be  great  difficulty  in  unfold- 
ing the  anterior  part  of  the  foot  owing  to  the  want  of  such  a  fixed  point. 

Tenotomy. — The  first  stage  in  the  treatment  consists  in  dividing 
all  the  various  tight  structures,  with  the  exception  of  the  tendo  Achillis. 
In  the  first  place,  the  tibial  tendons  which  interfere  with  reposition  of  the 
foot  must  be  divided,  and  in  bad  cases  the  tendon  of  the  flexor  longus 
digitorum  will  also  require  division. 

Division  of  the  Tibialis  anticus  Tendon. — The  tibialis  anticus  tendon  is 
usually  divided  just  below  the  point  where  it  crosses  the  ankle  joint  and 
just  above  its  insertion  into  the  internal  cuneiform  bone  (see  Fig.  103) ; 
at  this  point  there  is  no  risk  of  dividing  any  other  structure.  The  tendon 
can  be  defined  by  abducting  and  everting  the  foot  and  thus  making  it 
tense.  A  tenotomy  knife  is  inserted  on  one  side,  close  to  the  tendon,  which 
should  be  relaxed  so  as  to  allow  the  knife  to  be  insinuated  between  it  and 
the  skin.  The  cutting  edge  of  the  tenotome  is  then  turned  towards  the 
tendon,  which  is  again  put  upon  the  stretch  and  divided. 

Division  of  the  Tibialis  posticus  Tendon. — The  tibialis  posticus  tendon 
is  best  divided  through  an  open  incision  two  inches  above  the  internal 
malleolus,  and  immediately  behind  it  (saa  Fig.  103).  Instead  of  cutting 


TALIPES  EQUINO-VARUS  35i 

directly  down  on  to  the  tendon,  it  is  well  to  turn  aside  a  flap  so  as 
to  avoid  any  risk  of  adhesion  of  the  tendon  to  the  cicatrix  in  the  skin. 
An  incision,  with  its  convexity  forwards,  is  therefore  made  along  the 
internal  border  of  the  tibia,  and  the  flap,  containing  skin  and  fascia,  is 
turned  back  until  the  edge  of  the  tibia  is  exposed  ;  just  behind  this  will 
be  found  the  tendons  of  the  tibialis  posticus  and  the  flexor  longus  digi- 
torum.  The  former  tendon  lies  next  the  bone,  and  a  blunt-pointed  teno- 
tomy  knife  can  be  insinuated  flatwise  between  it  and  that  of  the  flexor 
longus  digitorum.  The  edge  of  the  knife  is  then  turned  towards  the  bone 
and  the  tendon  of  the  tibialis  divided.  Should  it  be  found  that  there  is 
still  some  obstacle  to  abducting  the  foot,  the  tendon  of  the  flexor  longus 
digitorum  may  also  be  cut ;  this,  however,  should  be  done  on  a  different 
level  to  that  on  which  the  division  of  the  tibialis  posticus  has  been  effected. 
The  wound  is  stitched  up  without  a  drainage  tube. 

Division  of  the  Plantar  Fascia. — The  plantar  fascia  if  contracted  must 
next  be  divided.  This  is  necessary  in  many  cases,  and  should  be  done 
near  the  centre  of  the  sole.  A  tenotomy  knife  is  introduced  from  the 
inner  side  of  the  foot,  and  carried  across  between  the  skin  and  the  fascia  ; 
it  is  important  to  remember  that  the  skin  is  very  close  to  the  fascia,  and 
that  all  resisting  bands  must  be  divided.  As  soon  as  one  band  is  cut 
across,  extension  made  upon  the  sole  causes  others  to  become  tense,  and 
these  must  also  be  divided,  either  from  the  same  puncture  or  from  another 
more  conveniently  situated.  It  is  important  that  the  division  of  the 
plantar  fascia  should  be  thorough  (see  Fig.  103). 

In  most  cases  also,  it  is  important  to  divide  the  ligaments  which 
oppose  reduction.  It  is  true  that  in  comparatively  mild  cases  the  tight 
ligamentous  structures  may  be  torn  across  at  this  stage  by  forcibly 
wrenching  the  foot  into  position,  either  with  the  hand  alone,  or  with  a 
Thomas's  wrench,  but  in  the  majority  it  is  much  better  to  divide  the 
ligaments  systematically  in  the  manner  recommended  by  Parker.  The 
anterior  part  of  the  internal  lateral  ligament  of  the  ankle  joint  in  particular, 
if  not  divided,  usually  escapes  tearing  when  the  foot  is  wrenched,  and  may 
interfere  considerably  with  reposition  of  the  os  calcis.  Parker  also  lays 
great  stress  on  what  he  terms  the  '  astragalo-scaphoid  capsule,'  which 
is  made  up,  above  and  internally,  of  the  superior  astragalo-scaphoid 
ligament  reinforced  by  fibres  from  the  anterior  ligament  of  the  ankle 
joint  and  the  anterior  portion  of  the  internal  lateral  ligament,  and, 
below,  of  fibres  from  the  inferior  calcaneo-scaphoid  ligament. 

Syndesmotomy,— Under  this  name,  Parker  has  described  an  operation 
by  which  both  tendons  and  ligaments  may  be  divided  through  one 
incision.  He  makes  a  puncture  a  little  below  and  in  front  of  the  tip  of 
the  internal  malleolus,  noting  at  the  same  time  the  position  of  the  tibial 
arteries,  and  the  direction  of  the  tibial  tendons  as  they  curve  towards 
the  internal  cuneiform  bone.  As  the  tenotomy  knife  is  entered,  the  parts 
are  fully  relaxed,  and  it  is  pushed  inwards  over  the  dorsum  just  above 


352  DEFORMITIES 

the  posterior  tibial  artery,  and  in  front  of  the  tendons,  to  a  point  just 
above  the  anterior  tibial  vessel.  Parker  employs  at  first  a  sharp-pointed 
tenotome  to  make  the  track  along  which  he  then  introduces  a  curved  one 
until  its  tip  can  be  felt  in  front  of  the  tendon  of  the  tibialis  anticus.  The 
cutting  edge  is  then  turned  downwards,  the  parts  fully  put  on  the  stretch, 
and  the  tibialis  anticus  tendon  is  divided ;  as  the  knife  cuts  down  on 
the  subjacent  bones  and  cartilage,  the  ligaments  yield,  while,  on  with- 
drawing the  knife,  the  tendon  of  the  tibialis  posticus  is  divided.  The 
essential  point  in  this  operation  is  the  division  of  the  ligaments,  which 
must  be  very  thorough.  Should  the  tibialis  posticus  not  be  divided 
on  withdrawing  the  knife,  it  can  be  done  afterwards  through  a  separate 
incision  (see  p.  350). 

Wrenching. — After  these  structures  have  been  divided,  the  foot  should 
be  forcibly  wrenched  into  position,  and  the  deformity  over-corrected ; 
that  is  to  say,  the  foot  should  be  brought  into  a  position  of  full  abduction 
and  eversion.  If  this  can  be  effected  by  the  hand,  it  is  best,  because 
the  surgeon  is  then  enabled  to  judge  how  much  force  he  is  employing, 
and  at  the  same  time  there  is  not  that  bruising  of  the  anterior  part  of 
the  foot,  which  is  a  necessary  accompaniment  of  the  use  of  wrenches. 
Lorenz  has  introduced  a  hard  wedge-shaped  support  which  is  useful 
as  a  fulcrum  over  which  to  unfold  the  foot  and  very  considerable  force 
can  be  exercised  in  this  way  provided  that  the  foot  be  large  enough  to  be 
grasped  easily  in  the  hands.  When  the  foot  is  very  small,  however,  it  is 
difficult  to  get  a  proper  hold  of  it,  and  then,  it  may  be  necessary  to  employ 
some  instrument,  the  best  being  Thomas's  wrench  (see  Fig.  116).  Thomas's 
wrench  is  composed  of  two  parallel  metal  bars  covered  with  thick  india- 
rubber,  which  can  be  approximated  or  separated  by  means  of  a  screw  in 
the  handle.  One  bar  is  placed  transversely  beneath  the  sole  of  the  foot, 
just  behind  the  ball  of  the  great  toe,  whilst  the  other  lies  parallel  to  it  over 
the  dorsum.  The  bars  are  then  approximated  until  the  foot  is  well 
grasped,  and  it  is  then  possible  to  manipulate  the  foot  with  ease. 

After-treatment. — When  all  the  resisting  structures,  with  the  exception 
of  the  tendo  Achillis,  have  been  divided,  a  collodion  dressing  is  applied 
over  the  tenotomy  puncture,  and  the  foot  fixed  temporarily  on  a  splint. 
For  the  first  three  days  the  best  arrangement  is  an  internal  splint  applied 
to  the  foot  and  leg.  When  the  equinus  is  extreme,  the  foot  lies  almost  in 
the  same  straight  line  with  the  leg  after  correction  of  the  varus  deformity, 
and  therefore  the  adduction  of  the  foot  and  the  inward  bend  at  the 
transverse  tarsal  joint  can  be  remedied  by  a  straight  internal  splint  applied 
from  the  knee  to  the  toes.  When  the  wounds  have  healed,  it  is  well  to  put 
up  the  foot  temporarily  in  a  Sayre's  apparatus,  around  which  plaster  of 
Paris  is  applied  as  already  described  (see  p.  348).  The  subsequent  treat- 
ment will  depend  to  a  large  extent  upon  the  patient's  surroundings.  In 
hospital  patients  who  cannot  afford  an  elaborate  apparatus  and  who  are 
unable  to  give  proper  attention  to  the  care  of  the  foot,  it  is  best  to  continue 


TALIPES  EQUINO-VARUS 


353 


with  the  plaster  of  Paris  bandages,  which  should  be  renewed  about  once 
a  week,  for  six  months.  Every  time  the  bandages  are  renewed  the  leg 
should  be  well  nibbed  and  the  galvanic  current  applied  to  the  muscles. 

At  the  end  of  about  six  weeks,  or  in  some  cases  even  earlier,  it  will 
generally  be  possible  to  carry  out  the  second  stage  of  the  treatment, 
namely  the  correction  of  the  talipes  equinus.  Before  doing  this,  however, 
the  foot  must  be  examined  to  see  whether  any  fresh  contraction  of  the 
ligaments  or  the  plantar  fascia  has  occurred.  Should  contraction  have 
recurred,  the  tenotomy  and  wrenching  must  be  repeated  before  the  tendo 
Achillis  is  divided.  The  best  indication  as  to  the  proper  time  for  the 
correction  of  the  talipes  equinus  is  that  the  foot  should  retain  its  corrected 


FIG.  1 16. — THOMAS'S  WRENCH. — A  shows  the  wrench,  B,  C,  and  D  the  methods  of 
using  it  in  a  case  of  talipes  equino-varus.     (Robert  Jones.) 

position  when  the  apparatus  is  taken  off,  or,  at  any  rate,  it  should  be 
possible  to  make  it  resume  it  at  once  by  gentle  pressure.  When  this 
stage  has  been  reached,  the  tendo  Achillis  is  divided  and  the  equinus 
treated  on  the  lines  already  laid  down  (see  p.  322).  About  three  weeks 
later  the  patient  may  be  allowed  to  walk  about  wearing  a  suitable  appa- 
ratus ;  for  poor  people  the  most  convenient  is  Sayre's  (see  Fig.  104)  which 
should  be  renewed  every  week. 

If  the  patient  can  afford  a  suitable  apparatus,  it  is  best  to  employ 
a  suitable  shoe  or  splint  about  three  weeks  after  the  tenotomy ;  with  the 
use  of  this  should  be  combined  massage  and  the  application  of  electricity. 
In  infants  the  light  metal  splint  already  described  (see  p.  316)  is  the  best. 
This  splint  should  be  applied  with  the  foot  in  the  faulty  position,  and  the 
varus  deformity  subsequently  over-corrected  ;  it  should  be  taken  off  night 
and  morning  for  massage  and  galvanisation  of  the  muscles. 

When  the  child  learns  to  walk,  or  when  treatment  is  not  begun  until 


AA 


354 


DEFORMITIES 


the  child  is  able  to  walk,  a  Scarpa's  shoe  may  be  applied  and  should  be 
worn  continuously  for  many  months  and  sometimes  for  years.  Although 
the  deformity  may  seem  to  be  corrected  perfectly,  it  takes  a  considerable 
time  for  the  shape  of  the  bones  to  be  influenced  materially,  and  the 
deformity  will  inevitably  be  reproduced  if  the  apparatus  be  left  off  too 
soon,  and  often  in  a  more  severe  form  than  the  original  one. 


FIG.  117. — SCARPA'S  SHOE.  On  the  right-hand  side  is  seen  the  apparatus  before  use. 
The  two  ratchets  (turned  by  the  key  shown  below  the  figure),  the  lower  one  for  flexing 
and  extending  the  ankle,  and  the  upper  for  inverting  or  everting  the  foot,  are  seen  near 
the  junction  of  the  outside  leg-iron  with  the  foot-piece.  The  broad  sling  used  to  pull 
outwards  the  front  part  of  the  foot  is  also  seen  in  front  attached  to  a  button  on  the  end 
of  the  stout  spring  attached  to  the  outer  side  of  the  sole  and  exerting  a  forcible  outward 
pull. 

In  the  left-hand  figure  the  apparatus  is  applied  to  a  case  of  equino-varus.  The  foot  is 
firmly  everted,  the  toes  raised,  the  heel  depressed,  and  the  front  half  of  the  foot  pulled 
outwards. 

In  Scarpa's  shoe  (see  Fig.  117)  there  is  a  leg-piece  applied  to  the  calf, 
on  the  outer  side  of  which  is  attached  an  iron  bar  connected  with  a 
foot-piece.  Opposite  the  ankle  there  are  two  hinges,  one  corresponding 
to  the  ankle  joint  proper,  from  which  flexion  and  extension  of  the 
foot-piece  is  made,  whilst  the  other  raises  or  depresses  the  side  of 
the  foot  so  as  to  bring  it  into  a  position  of  eversion  or  inversion.  A  strong 
spring  bent  considerably  outwards  is  fixed  to  the  outer  side  of  the  front 
of  the  foot-piece  and  from  this  a  band  is  carried  around  the  anterior  part 
of  the  foot  which  can  thus  be  brought  into  a  position  of  abduction,  by  the 


TALIPES  EQUINO-VARUS  355 

outward  pull  of  the  spring.  In  some  forms  of  the  apparatus  this  move- 
ment is  reinforced  by  a  joint  in  the  foot-piece  beneath  the  instep,  which 
is  made  to  carry  the  front  half  outwards,  by  means  of  a  screw  ;  this  effects 
more  powerful  abduction  of  the  front  of  the  foot. 

When  applying  a  Scarpa's  shoe,  the  apparatus  is  first  screwed  into  a 
position  corresponding  with  the  deformity,  and  the  heel  is  carefully  fixed 
down  to  the  foot-piece  by  the  appropriate  straps.  The  apparatus  is  then 
fastened  to  the  leg,  and  the  various  racks  are  turned  with  keys,  and  the 
deformity  is  reduced  as  far  as  possible  without  giving  pain.  The  reduction 
should  not  be  carried  so  far  as  to  cause  pain,  and  there  should  be  no  undue 
pressure  upon  the  straps  which  pass  across  the  instep  and  fasten  the  heel 
to  the  splint,  as  otherwise  sores  may  form  beneath  them.  Much  more 
will  be  done  by  gentleness  and  gradual  reduction  of  the  deformity  than 
by  any  violent  attempt  to  over-correct  it  at  once  ;  the  correction  should 
be  increased  gradually  until  the  deformity  is  over-corrected  (see  Fig  117). 

The  apparatus  is  best  suited  for  children  who  can  walk ;  in  a  very 
young  child  the  foot  is  too  small  for  the  shoe  to  get  proper  purchase, 
and  therefore  the  lighter  metal  splint  is  preferable.  The  shoe  should  be 
worn  night  and  day,  and  should  only  be  taken  off  for  toilet  purposes  and 
for  massage.  The  child  may  walk  while  wearing  the  apparatus,  and  its 
use  should  be  continued  for  a  year  or  two,  when  a  lighter  apparatus 
may  be  substituted  for  it,  which  will  have  to  be  worn  for  two  or  three 
years  longer.  As  soon  as  the  foot  will  retain  its  position  when  the  child 
stands  or  walks,  the  splint  may  be  dispensed  with,  but  even  then  it  is  well 
to  see  that  the  boots  are  made  to  a  cast  of  the  foot  in  its  corrected  position, 
and  in  some  cases  a  suitable  spring  or  an  artificial  sole  is  requisite  to 
raise  the  outer  border  of  the  foot.  Even  after  the  lapse  of  this  length  of 
time  it  is  well  to  put  on  the  apparatus  at  night  for  another  year  or  two  in 
order  to  prevent  the  foot  assuming  the  faulty  position  during  sleep. 

The  most  severe  Cases  of  Deformity — The  greatest  difficulty 
arises  in  the  treatment  of  the  third  group  of  cases  in  which  the  most 
important  obstacle  to  reduction  is  permanent  alteration  in  the  bones. 
These  cases  may  be  divided  into  those  in  which  the  patient  is  still 
young  and  the  bones  are  soft  and  capable  of  being  moulded,  although 
the  deformity  in  the  osseous  structures  of  the  foot  may  be  considerable, 
and  those  in  which  the  condition  has  remained  untreated  into  adult 
life,  and  in  which  therefore  the  bones  are  fully  ossified  and  unyielding.  In 
young  subjects  it  is  sometimes  possible,  even  when  there  is  marked 
deformity,  to  alter  the  shape  of  even  considerably  deformed  bones  and  to 
bring  the  foot  gradually  to  its  proper  position  by  keeping  up  continuous 
pressure  in  the  desired  direction  ;  this  treatment  is  carried  out  in  com- 
bination with  free  division  of  the  resisting  soft  structures.  In  the  more 
advanced  cases,  however,  it  is  necessary  to  employ  operative  interference 
to  remedy  the  deformity  of  the  bones. 

The   treatment  of  the  first  group  of  cases  consists  either  in  dividing 

AA  2 


356  DEFORMITIES 

all  the  resisting  structures  subcutaneously,  and  bringing  the  foot 
forcibly  into  position  by  wrenches,  after  which  an  apparatus,  designed 
to  keep  up  constant  pressure  on  the  bones,  is  applied,  so  as  to  mould 
them  to  their  natural  shape  ;  or  in  performing  an  open  operation  by 
which  all  the  soft  structures  causing  the  faulty  position  of  the  foot  are 
divided,  and  subsequently  applying  pressure  in  such  a  direction  as  to 
produce  the  required  alteration  in  the  shape  of  the  bones.  This  is  com- 
monly known  as  '  Phelps'  operation.' 

The  forcible  restoration  of  the  foot  with  wrenches  after  all  the  resisting 
soft  structures  have  been  divided  subcutaneously  is  done  in  the  manner 
already  described  (see  p.  352).  Any  tight  tendons,  the  astragalo-scaphoid 
capsule,  the  plantar  fascia  and  the  internal  lateral  ligament  of  the  ankle 
joint,  are  divided  with  a  tenotome  and  this  is  followed  by  wrenching  of 
the  foot,  so  as  to  tear  any  ligamentous  structures  that  may  have  escaped 
division.  The  later  treatment  consists  in  dividing  the  tendo  Achillis  and 
employing  apparatus  to  keep  up  constant  pressure  on  the  foot  in  the 
right  direction,  and  thus  gradually  to  alter  the  axes  of  the  deformed  bones. 
Nothing  further  need  be  said  here  concerning  this  method  which  is  only 
an  extension  of  that  already  described  for  the  second  group  of  cases. 

In  carrying  it  out,  subcutaneous  division  of  the  tight  structures 
must  often  be  repeated  after  an  interval  of  a  few  weeks,  and  the  wrenching 
also  requires  more  than  one  repetition.  If  success  be  not  attained 
after  a  fair  trial  of  this  method  for  six  months  or  a  year,  the  surgeon 
must  employ  Phelps's  operation  or  some  modification  of  it. 

Phelps's  operation  is  performed  as  follows.  The  foot  is  placed  on 
its  outer  side  upon  a  firm  sandbag,  and  an  incision  is  commenced  about 
half  an  inch  in  front  of  the  tip  of  the  internal  malleolus,  and  extended 
downwards  and  slightly  forwards,  to  the  sole.  This  incision  should  not 
go  farther  down  than  the  middle  point  of  the  sole,  as  otherwise  trouble 
may  ensue  afterwards  from  pressure  upon  the  scar  in  walking  ;  it 
should  commence  above,  in  close  proximity  to  the  tendon  of  the  tibialis 
anticus,  and  should  divide  all  the  structures  down  to  the  bone,  parallel 
to,  and  slightly  in  front  of,  the  marked  transverse  crease  in  the  foot  which 
corresponds  roughly  to  the  mid-tarsal  articulation.  The  tendons  of  the 
tibialis  anticus  and  posticus  muscles,  the  plantar  fascia,  the  abductor 
hallucis,  the  flexor  brevis  and  part  of  the  flexor  longus  digitorum,  together 
with  the  internal  plantar  vessels  and  nerve,  are  divided  in  this  incision. 
A  portion  of  the  internal  lateral  ligament  of  the  ankle  joint,  and  the 
ligaments  about  the  mid-tarsal  joint,  are  also  cut,  and  thus  the  head  of 
the  astragalus  is  exposed.  The  foot  is  next  forcibly  wrenched  into  a 
position  of  abduction,  and  after  this  a  deep  triangular  gap  is  left  in  the 
position  of  the  incision,  which  may  either  be  allowed  to  heal  by 
granulation,  which  is  a  slow  process,  or  may  be  covered  by  skin-grafts 
(see  p.  52). 

The  foot  is  secured  to  a  splint  in  the  over-corrected  position.     Should 


TALIPES  EQUINO-VARUS  357 

the  tendo  Achillis  require  division,  as  it  generally  does,  this  is  better 
done  after  an  interval  of  six  or  eight  weeks,  for  reasons  already  mentioned 
(see  p.  350).  When  the  wound  has  healed,  the  foot  may  be  put  up  in 
plaster  of  Paris,  and  the  after-treatment  requires  careful  attention.  In 
these  bad  cases  there  is  a  strong  tendency  for  the  deformity  to  recur,  and 
this  is  greatly  aided  by  the  contraction  of  the  large  scar  left  on  the  inner 
side  of  the  foot ;  care  must  be  taken  therefore  to  counteract  this  tendency. 
The  safest  way  to  prevent  recurrence  is  to  over-correct  the  deformity  so 
fully,  by  free  incision  of  the  astragalo-scaphoid  articulation,  that  the  foot 
is  actually  in  a  condition  of  slight  valgus.  Locomotion  then  becomes  a 
valuable  aid  in  preventing  any  recurrence  of  the  varus.  The  treatment 
of  these  cases  after  the  wound  has  healed  is  similar  to  that  for  those  in 
which  a  less  severe  operation  has  been  done. 

In  order  to  mitigate  the  severity  of  this  operation,  it  has  been  done 
subcutaneously  by  introducing  the  knife  between  the  skin  and  the  deeper 
parts,  and  then  cutting  everything  right  down  to  the  bone.  The  objec- 
tion to  this  is  that  the  skin  itself  is  always  markedly  shortened,  and  will 
not  stretch  ;  sloughing  therefore  is  likely  to  occur  from  the  pressure  of 
the  extravasated  blood  beneath  the  skin,  which  is  rendered  unduly  tense 
both  by  it  and  by  the  pressure  brought  to  bear  when  the  foot  is  forcibly 
straightened. 

Phelps's  operation  has  been  very  successful  in  many  cases,  although  it  is 
a  somewhat  drastic  one.  The  operation  is  more  suitable  for  young  children 
in  whom  the  bones  are  still  soft,  and  in  whom  the  soft  parts  have  con- 
tracted to  such  an  extent  that  the  deformity  cannot  be  remedied  by 
mere  subcutaneous  division.  It  is  not  likely  to  be  so  successful  in  adults, 
or  in  those  in  whom  the  bone  changes  are  extensive  and  permanent. 
It  has  little  chance  of  success  in  any  case  unless  the  incision  and  wrenching 
are  so  free  that  the  foot  afterwards  is  actually  in  a  position  of  valgus 
rather  than  varus.  It  is  neglect  of  this  precaution  that  has  led  to  so 
many  unsuccessful  results. 

The  operation  required  for  the  most  severe  eases,  such,  for  in- 
stance, as  those  where  the  patient  has  been  allowed  to  grow  up  with 
the  deformity  uncorrected,  will  necessarily  be  more  radical,  and  must 
involve  resection  of  some  portion  of  the  tarsus.  Whether  or  not  operative 
interference  should  be  undertaken  will  depend  very  much  on  the  functional 
condition  of  the  foot  ;  some  of  these  patients  become  so  accustomed  to 
use  the  limb  with  the  foot  in  the  deformed  position  that  they  can  walk 
well,  and  hence  it  is  inadvisable  to  suggest  operation  to  them,  considering 
the  severity  of  the  operation,  and  the  more  or  less  imperfect  result  which 
may  follow  it.  In  other  instances,  however,  there  is  so  much  pain  and 
difficulty  in  walking  from  the  formation  of  bursae  on  the  outer  side  and 
dorsum  of  the  foot,  which  are  constantly  liable  to  repeated  attacks  of 
inflammation,  that  the  patient  urgently  demands  relief  by  operation, 
which  is  then  fully  justified. 


358  DEFORMITIES 

Amputation. — In  those  cases  in  which  the  exaggerated  deformity  is 
the  result  of  infantile  paralysis,  and  in  which  there  is  almost  complete 
uselessness  of  the  foot,  the  question  of  amputation  will  arise.  The 
answer  mainly  depends  upon  the  vitality  of  the  parts.  In  the  paralytic 
forms  the  tissues  are  often  imperfectly  nourished,  ulcers  are  liable  to 
form  from  the  most  trivial  causes,  chilblains  are  common,  and  consequently 
the  result  of  extensive  operations  upon  the  skeletal  structures  of  the  foot 
is  not  satisfactory.  Under  these  circumstances  therefore  it  is  rnuch 
better  to  amputate,  and  to  fit  the  patient  with  an  artificial  limb,  as  he 
will  then  have  a  useful  limb  and  be  free  from  trophic  troubles,  which 
would  not  be  the  case  after  any  partial  operation  which  involves  retention 
of  the  foot.  In  the  congenital  cases  on  the  other  hand,  in  which  the 
nutrition  of  the  foot  is  good,  the  question  of  amputation  will  only  arise 
very  rarely  ;  it  is  only  called  for  when  repeated  attacks  of  inflammation 
and  suppuration  in  the  various  bursse,  possibly  extending  into  the  joints, 
have  rendered  the  chance  of  remedying  the  condition  by  any  form  of 
tarsectomy  very  remote  indeed.  In  such  cases,  Syme's  amputation  will 
leave  the  patient  in  a  much  better  condition  than  before  operation,  or 
than  could  be  obtained  by  any  form  of  tarsectomy. 

The  osteo-plastic  operations  practised  for  the  cure  of  club-foot  are 
numerous,  but  for  practical  purposes  they  may  be  divided  into  two 
groups.  In  the  first  are  those  in  which  one  or  more  of  the  tarsal  bones  are 
excised,  and  in  the  second  are  the  operations  involving  the  removal  of 
wedge-shaped  portions  of  the  tarsus  without  any  regad  to  the  articulations 
of  the  portion  removed.  The  operations  included  in  the  first  group  are 
numerous.  Various  tarsal  bones,  more  particularly  the  astragalus  and 
the  cuboid,  have  been  removed,  but  the  results  do  not  appear  to  be 
particularly  good ;  removal  of  the  astragalus,  although  of  some  value 
as  a  cure  for  the  equinus,  does  not  seem  to  influence  the  varus  part  of  the 
deformity  to  any  extent. 

The  removal  of  wedge-shaped  portions  of  the  tarsus  without  regard 
to  the  articulation  of  the  portion  removed,  on  the  other  hand,  is  a  valuable 
method.  The  operation,  which  is  generally  spoken  of  as  '  cuneiform 
tarsectomy'  consists  in  removing  a  wedge-shaped  portion  of  the  tarsus 
at  the  transverse  tarsal  joint  by  means  of  a  saw  or  chisel,  the  portion 
thus  excised  having  its  base  directed  outwards  and  slightly  upwards, 
whilst  its  apex  is  at  the  inner  border  of  the  sole.  The  amount  of  bone 
taken  away  will  vary  with  the  degree  of  deformity  present,  the  object 
being  to  remove  sufficient  to  permit  the  outer  border  of  the  foot  to  be 
shortened  to  the  degree  requisite  to  bring  the  concave  inner  border  straight. 
The  parts  included  in  this  excision  generally  comprise  portions  of  the 
os  calcis,  astragalus,  cuboid,  and  scaphoid. 

The  operation  is  performed  as  follows.  The  limb  is  steadied  upon  a 
sandbag,  and  the  surgeon  divides  all  the  shortened  tendons,  fascia  and 
ligaments  that  can  be  reached  on  the  inner  side  of  the  foot  with  a  teno- 


TALIPES   EQUINO-VARUS 


359 


tomy  knife.  This  is  similar  to  Parker's  syndesmotomy  (see  p.  351).  It  is 
important  to  do  this  before  proceeding  to  divide  bone,  as  otherwise  an 
unnecessarily  large  amount  of  the  tarsus  will  have  to  be  removed  in  order 
to  get  the  foot  into  position.  One  of  the  most  important  features  in  this 
preliminary  procedure  is  the  free  division  of  the  front  part  of  the  internal 
lateral  ligament  of  the  ankle  joint,  which  will  allow  the  os  calcis  to  be 
pressed  outwards  towards  its  normal  position,  for  in  these  bad  cases  the 
patient  generally  walks  upon  the  outer  side  of  the  os  calcis  as  well  as  upon 
the  outer  aspect  of  the  dorsum  of  the  foot.  It  is  also  advantageous  to 
amplify  the  freedom  of  movement  obtained  after  tenotomy  by  the  use 
of  Thomas's  wrench  (see  p.  352). 


FIG  118— CUNEIFORM  TARSECTOMY  FOR  TALIPES  EQUINO-VARUS.    The  black  line 
indicates  the  incision.    The  darker  portion  indicates  the  amount  of  bone  that  must 
removed. 

After  all  the  tight  structures  on  the  inner  side  of  the  foot  have  been 
divided  or  stretched  to  their  utmost  extent,  the  surgeon  makes  an  incision 
along  the  outer  border  of  the  foot,  commencing  at  the  base  of  the  fifth 
metatarsal  and  terminating  just  in  front  of  and  about  an  inch  below  the 
tip  of  the  external  malleolus.     This  incision  is  carried  directly  down  t< 
the  bone  and  the  soft  parts  are  raised  in  one  mass  from  both  dorsal  and 
plantar  surfaces  of  the  tarsus  with  a  periosteum  detacher.     The  operation 
is  greatly  facilitated  by  making  a  second  incision  along  the  inner  border 
of  the  foot,  commencing  just  below  and  in  front  of  the  tip  of  the  internal 
malleolus  and  terminating  a  finger's  breadth  behind  the  base  of  the  f 
metatarsal.     This  enables  the  soft  structures  to  be  raised  from  tl 
on  the  inner  side  and  thus  the  tarsus  can  be  denuded  of  all  the  soft  stri 
tures,  above  and  below,  opposite  the  two  incisions.     It  will  be  necessary 


360 


DEFORMITIES 


to  divide  a  portion  of  the  extensor  Drevis  digitorum  muscle  at  its  origin, 
and  the  insertion  of  the  tibialis  posticus  tendon  into  the  scaphoid  will 
probably  be  cut  through.  The  soft  parts  are  retracted  and  protected  from 
injury  by  introducing  beneath  them  flexible  copper  spatulae  of  suitable 
breadth,  by  which  they  can  be  pulled  away  from  the  bone. 

The  next  stage  is  the  removal  of  a  wedge-shaped  portion  of  the  tarsus. 
The  amount  of  bone  to  be  removed  will  depend  upon  the  degree  of  the 
deformity,  only  sufficient  being  taken  away  to  enable  the  foot  to  come 
straight.  The  section  through  the  bone  is  best  effected  by  a  broad  chisel 
(by  means  of  which  the  surgeon  is  enabled  to  vary  the  amount  removed 
at  different  parts),  but  it  is  well  to  mark  out  the  intended  dimensions  of 
the  wedge  with  a  narrow  saw  as  a  preliminary  measure.  The  base  of  the 
wedge  looks  towards  the  upper  and  outer  surfaces  of  the  tarsus,  while  its 
apex  is  at  the  inner  border  of  the  sole.  After  the  section  has  been  made, 

the  bleeding  is  arrested  and  the  foot 
brought  into  position  ;  if  the  section 
has  been  made  as  directed  above,  the 
front  part  of  the  foot  will  be  raised 
and  brought  into  a  position  of 
slight  abduction.  If  the  position 
be  not  satisfactory,  more  bone  may 
be  sawn  off  ;  if  it  be,  the  incisions 
are  stitched  up  without  a  drainage 
tube.  It  frequently  happens  that 
the  skin  over  the  instep  is  made  very 
tight  when  the  foot  is  brought  into 
the  corrected  position.  This  is  due 
to  shrinkage  resulting  from  the 
long  continuance  of  the  limb  in  its  faulty  position,  and  if  both  the 
incisions  were  stitched  up  longitudinally  a  deep  transverse  groove  would 
form  between  them  over  the  dorsum  of  the  foot,  and  the  tension 
would  be  so  great  as  to  cause  sloughing.  We  are,  therefore,  accustomed 
to  stitch  up  the  wound  on  the  inm  r  side  in  the  ordinary  way  first,  and 
then,  to  suture  the  external  one  in  any  manner  that  will  give  rise  to  the 
least  tension  of  the  skin  over  the  instep  after  having  brought  the  foot 
straight.  As  a  rule  this  incision  takes  a  somewhat  JL -shape  ;  that  is  to 
say,  a  certain  portion  of  it  at  either  end  is  stitched  up  longitudinally,  but 
the  central  portion  of  the  upper  edge  of  the  wound  is  folded  upon  itself 
and  sutured  (see  Fig.  119). 

After  the  wound  has  been  sutured  and  the  dressings  have  been  applied, 
the  foot  is  placed  upon  a  back  splint  furnished  with  a  foot-piece  at  right 
angles,  and  care  must  be  taken  to  see  that  the  os  calcis  as  well  as  the 
anterior  part  of  the  foot  is  fully  everted.  It  is  well  to  leave  the  division 
of  the  tendo  Achillis  until  union  has  occurred  between  the  bony  surfaces. 
After  the  stitches  have  been  removed,  the  foot  is  put  up  in  plaster  of  Paris 


FIG.  119. — METHOD  OF  SUTURING  THE  WOUND 
AFTER  CUNEIFORM  TARSECTOMY.  The  upper  lip 
of  the  wound  is  folded  upon  itself  about  its  centre 
and  the  adjacent  edges  sutured  together. 


CLUB-HAND  36i 

in  the  rectified  position  and  is  kept  there  for  a  month.  The  tendo  Achillis 
and,  if  necessary,  the  posterior  ligament  of  the  ankle  joint,  should  be  then 
divided. 

In  very  severe  cases,  characterised  by  extreme  inversion  of  the  os 
calcis  and  severe  equinus,  it  may  be  advisable  to  begin  by  excising  the 
astragalus  (see  p.  332).  This  enables  the  equinus  to  be  remedied  and  the 
inversion  of  the  os  calcis  rectified.  The  varus  part  of  the  deformity  can 
be  treated  by  a  cuneiform  tarsectomy  undertaken  some  months  later. 

The  after-treatment  is  similar  to  that  recommended  for  talipes  equinus 
(see  p.  326),  the  chief  trouble  being  the  inversion  of  the  os  calcis,  which  is 
most  difficult  to  remedy.  The  patient  must  be  kept  under  mechanical 
treatment  by  suitable  shoes  for  at  least  two  or  three  years,  for,  even  after 
an  operation  of  this  radical  nature,  a  relapse  may  occur  if  the  treatment 
be  abandoned  too  soon.  Should  any  tendency  to  a  relapse  manifest  itself, 
it  may  be  overcome  at  an  early  stage  by  wrenching  the  foot  and  again 
putting  it  up  in  plaster  of  Paris ;  but  even  up  to  the  end  of  his  life  the 
patient  should  wear  specially  strong  boots  with  the  sole  somewhat 
thickened  along  the  outer  border,  and  the  inner  side  of  the  boot  cut 
straight,  and  made  of  very  stiff  leather  so  as  to  prevent  adduction  of  the 
front  part  of  the  foot. 

CLUB-HAND. 

This  deformity  is  comparatively  rare.  The  commonest  variety  is 
caused  by  congenital  absence  of  the  radius,  and  in  most  cases  is  associated 
with  absence  of  the  thumb.  Other  cases  occur  in  which  there  is  a  con- 
genital contraction  of  the  muscles,  usually  associated  with  wasting,  pro- 
ducing a  condition  analogous  to  that  found  in  the  common  variety  of 
talipes  equino-varus.  The  hand  is  deflected  to  one  side  and,  in  con- 
genital absence  of  the  radius,  lies  in  contact  with  the  forearm,  the  fingers 
pointing  towards  the  elbow  joint. 

TREATMENT. — This  is  unsatisfactory,  but  the  hand  is  almost 
useless  if  left  alone.  In  very  young  children  the  muscles  and  tendons  are 
so  delicate  and  friable  that  any  operation  for  lengthening  them  is  out  of 
the  question.  Further,  the  skin  on  the  radial  border  of  the  hand  is  so  con- 
tracted that  if  an  attempt  be  made  to  rectify  the  deformity  by  dividing 
the  skin,  an  exceedingly  large  wound  is  left,  the  cicatrisation  of  which  leads 
to  troublesome  swelling  of  the  hand.  Much  can  be  done  by  manipulation, 
however,  and  this  should  be  commenced  immediately  the  child  is  born. 
The  hand  is  gently  stretched  until  it  is  nearly  in  a  line  with  the  forearm  ;  a 
small  tubular  poroplastic  felt  splint  is  then  moulded  around  the  wrist  so 
as  to  maintain  the  correction.  As  the  child  gets  older,  the  shape  of  the 
splint  can  be  modified,  and  in  this  way  considerable  improvement  may  be 
obtained.  Operative  interference  should  not  be  attempted  until  the  child 
is  at  least  five  years  old.  The  contraction  of  the  skin  is  best  remedied  by 


362  DEFORMITIES 

the  use  of  the  Y-shaped  plastic  operation  described  on  p.  295,  and  many  of 
the  tendons  require  lengthening  (see  Vol.  II.).  After  the  tendons  have 
been  divided,  but  before  they  have  been  sutured,  the  soft  parts  should  be 
separated  from  the  lower  end  of  the  ulna,  and  the  bone  made  to  protrude 
through  the  wound.  The  bone  is  divided  lengthwise  with  a  fine  saw 
for  about  two  inches,  the  plane  of  the  saw  cut  being  at  right  angles  to  that  of 
the  palm.  A  periosteum  detacher  is  then  inserted  into  the  saw-cut  and 
the  two  portions  of  bone  forced  apart ;  this  will  cause  one  of  them  to 
undergo  a  greenstick  fracture.  At  the  carpal  end  of  the  cut  the  peri- 
osteum at  the  end  of  each  portion  of  bone  is  now  sutured  by  a  stout  catgut 
thread  to  the  carpus  ;  one  to  the  radial  and  one  to  the  ulnar  side.  The 
divided  and  lengthened  tendons  are  now  sutured  together  and  the  wound 
closed  as  far  as  possible.  If  the  wound  cannot  be  completely  closed  it 
should  be  allowed  to  granulate  and  then  skin-grafted.  When  healing  has 
taken  place,  the  hand  should  be  maintained  in  the  same  line  with  the  fore- 
arm by  encasing  them  in  a  tubular  sheet  of  poroplastic  felt  extending  from 
the  middle  of  the  forearm  to  the  base  of  the  fingers.  The  absence  of  the 
thumb  makes  the  application  of  the  splint  quite  simple.  For  the  cases  in 
which  both  bones  are  present,  the  most  suitable  treatment  is  by  manipula- 
tion and  massage  combined  with  the  use  of  the  poroplastic  splint  as 
described  above. 

The  results  of  this  treatment  are,  however,  far  from  ideal  as  there  is 
always  a  considerable  amount  of  muscular  weakness. 


CHAPTER   XVII. 
CURVED  TIBIA  AND  FIBULA. 

CURVATURE  of  the  bones  of  the  leg  is  one  of  the  commonest  results  of 
rickets.  A  certain  amount  of  curvature  of  these  bones  may  also  occur  in 
syphilis,  osteitis  deformans,  osteo-malacia,  and  some  other  diseases.  In 
the  cases  due  to  rickets  the  degree  and  situation  of  the  curve  vary  con- 
siderably. The  most  usual  condition  is  a  uniform  curvature  of  the  entire 
shaft  of  the  bone  with  the  convexity  outwards  and  somewhat  forwards, 
whilst  the  shaft  becomes  flattened  from  side  to  side,  and  there  is  a  tend- 
ency to  an  increased  production  of  bone  in  the  concavity  which  acts  as  a 
support.  In  other  cases  the  bend,  which  is  somewhat  more  acute,  occurs 
either  just  above  the  lower  epiphysis  or,  more  rarely,  a  little  below  the 
upper.  This  may  be  met  with  either  alone  or  in  combination  with  the 
uniform  outward  curvature.  In  rare  cases  the  tibia  may  be  convex 
inwards  instead  of  outwards.  The  conditions  met  with  most  frequently, 
however,  are  an  outward  bowing  of  the  tibia  or  an  acute  anterior  curve 
immediately  above  the  ankle,  or  a  combination  of  the  two. 

TREATMENT. — This  should  be  partly  general  and  partly  local. 

The  general  treatment  should  be  that  appropriate  for  rickets,  since 
this  disease  is  the  primary  cause  of  the  deformity.  The  whole  subject  of 
rickets  is  discussed  in  Vol.  II. ;  here  we  need  only  say  that  its  treatment 
is  partly  dietetic  and  partly  hygienic.  We  append  the  table  of  direc- 
tions given  to  the  mothers  of  rickety  children  at  Paddington  Green 
Children's  Hospital.  These  rules  embrace  both  dietetic  and  hygienic 
instruction,  and,  although  mainly  designed  for  the  use  of  hospital  out- 
patients, may,  with  a  little  modification,  be  applied  to  private  practice. 


FEEDING. 

I.  If  the  Mother  is  perfectly  healthy  and  has  plenty  of  Milk,  breast  milk 
alone  should  be  given  until  the  infant  is  8  months  old. 

Suckle  every  2  hours  by  day,  and  twice  by  night,  until  the  child  is  3  months 

363 


364  DEFORMITIES 

old ;  then  suckle  every  3  hours  by  day  and  once  only  by  night.  Too  frequent 
suckling  makes  the  milk  poor  and  does  not  satisfy  the  baby. 

The  mother's  nipples  should  be  bathed  with  warm  water  both  before  and  after 
suckling.  Also  wash  the  inside  of  the  child's  mouth  with  a  small  piece  of  clean 
linen  and  warm  water  after  taking  the  breast.  This  will  prevent  '  Thrush.' 

Begin  to  wean  at  8  months,  and  wean  completely  at  9  months. 

Between  the  eighth  and  ninth  months  let  the  child  have  three  times  a  day  a 
mixture  of  two  parts  of  cows'  milk  and  one  part  of  barley  water,  sweetened  with  one 
lump  of  sugar  or  one-third  of  a  teaspoonful  of  malt  extract  to  each  bottle.  The 
cows'  milk  should  be  just  brought  to  the  boil. 

The  barley  water  is  made  as  follows  :  Wash  one  tablespoonful  of  pearl  barley  and 
put  it  in  a  saucepan  with  one  pint  of  cold  water.  Let  it  come  to  the  boil,  and  then 
simmer  beside  the  fire  for  half-an-hour.  Strain  and  use  as  required.  Should  be 
prepared  twice  daily. 

II.  If  the  Mother  has  only  a  little  Milk,  the  child  should  still  have  it :  give 
also  one  part  cows'  milk  and  two  parts  barley  water,  made  and  sweetened  as  above. 

There  is  no  harm  in  mixing  the  milks.  It  is  better  to  get  ordinary  dairy  milk 
than  milk  from  one  cow. 

Should  diarrhoea  or  vomitirig  come  on,  give  equal  parts  of  milk,  lime  water,  and 
barley  water. 

ill.  If  for  any  reason  the  Breast  cannot  be  given,  feed  as  follows : 

Up  to  3  months. — One  part  of  cows'  milk  and  two  parts  of  barley  water— pre- 
pared and  sweetened  as  above — every  2  hours  by  day  and  twice  by  night.  Give 
one-sixth  of  a  pint  of  the  mixture  at  each  feed,  and  add  a  little  more  milk  each 
week  until — 

Between  3  and  6  months. — Equal  parts  of  cows'  milk  and  thin  barley  water 
may  be  given,  i£  to  2  pints  a  day.  One-third  of  a  teaspoonful  of  fresh  butter,  or  a 
teaspoonful  of  cream  may  be  given  twice  daily  in  the  milk.  Feed  every  3  hours  by 
day,  and  once  during  the  night. 

Between  6  and  9  months. — Two  parts  of  cows'  milk  to  one  part  of  barley 
water.  Then  add  gradually  more  milk  and  less  barley  water  until  at  9  months  the 
child  is  taking  plain  milk. 

On  no  account  give  any  infants'  food,  condensed  milk,  bread,  biscuits,  or  tops 
and  bottoms  until  the  child  is  9  months  old — except  by  doctor's  orders. 

If  the  cows'  milk  does  not  seem  to  agree,  consult  a  doctor — not  the  chemist. 

Never  give  babies  at  any  age  sweets,  pastry,  fruits,  cheese,  salt  meat,  salt  or 
fried  fish,  tea,  wine,  beer,  or  spirits. 

Between  9  and  12  months. — Besides  I  pint  or  ij  pints  of  cows'  milk,  the 
child  may  be  given,  not  oftener  than  twice  in  the  day,  any  plain  milk  pudding,  or 
porridge  made  with  milk,  or  bread  and  milk  made  as  follows  :  Put  a  slice  of  stale 
bread  without  crust  to  soak  in  a  basin  of  cold  water  for  2  hours ;  then  pour  off  the 
water,  beat  up  the  bread,  and  pour  over  it  a  quarter  of  a  pint  of  boiling  milk  ;  sweeten 
with  l»af  sugar.  This  should  be  freshly  made  for  each  meal. 

Between  12  and  18  months. — Add  to  the  above,  potato  and  gravy,  or  half  an 
egg  once  in  a  day.  After  15  months,  feed  every  4  hours  by  day  and  not  at  all 
during  the  night. 

After  18  months. — Finely  minced  or  shredded  mutton  and  fresh  fish  may  be 
added  to  the  above,  but  cows'  milk  should  still  be  the  principal  food. 

Feed  only  at  meal  times,  never  between  meals,  '  Just  to  keep  the  baby 
quiet.'  Babies  often  cry  not  because  they  are  hungry,  but  because  they  are 
thirsty.  A  little  pure  water  or  barley  water,  flavoured  with  orange  juice,  will 
satisfy  them. 

The  bottle  should  have  a  nipple,  but  no  tube.  Scald  it  out  both  before  and 
after  use,  and  cleanse  with  a  brush. 


CURVED  TIBIA  AND  FIBULA  365 

Prepare  at  a  time  only  enough  milk  for  one  meal.  Never  give  what  is  left  over 
in  the  bottle  for  the  next  meal.  Taste  the  milk  before  feeding,  and  be  sure  it  is  not 
sour  or  smoked. 

GENERAL  DIRECTIONS. 

I. — Sleeping. — The  child  should  sleep  in  a  cot  or  basket  alone.  Many  babies 
are  overlaid  every  year  from  sleeping  with  their  parents. 

If  babies  kick  off  the  bedclothes,  put  them  in  long  flannel  nightgowns,  fastened 
below  the  feet  and  at  the  wrists  and  throat.  They  must  not  lie  between  window 
and  door,  or  fireplace  and  door.  Keep  the  window  open  all  night  in  hot  weather. 
Keep  a  small  fire  burning  all  night  in  cold  weather. 

II. — Clothing. — Should  be  loose  round  the  chest  and  close  round  the  belly.  Do 
not  let  them  go  about  with  nothing  on  below  the  armpits  but  petticoats.  A  flannel 
binder  round  the  belly  and  warm  drawers  should  always  be  worn. 

III. — Washing. — Wash  them  all  over  with  soap  and  warm  water  night  and 
morning.  Dirty  children  are  always  delicate.  They  will  not  take  cold  if  carefully 
dried,  especially  about  the  head  and  ears,  after  the  bath.  It  is  a  good  plan  to  put 
them  to  bed  between  the  blankets  for  half-an-hour  after  the  morning  bath. 

IV. — Fresh  Air  and  Sunlight  are  nearly  as  important  as  food  to  children.  Take 
them  out  every  day  in  fine  weather. 

A  perusal  of  these  rules  will  show  that  the  dietetic  treatment  consists 
largely  in  the  avoidance  of  too  much  farinaceous  food,  and — a  point  of 
particular  importance — the  withholding  of  it  at  an  early  period  of  life. 
The  hygienic  treatment  is  directed  essentially  to  obtaining  an  unlimited 
supply  of  pure  fresh  air  and  sunshine.  If  possible,  the  children  should  be 
sent  away  to  the  country,  and  of  course  any  other  measures  for  improving 
the  general  health  that  may  be  found  appropriate  to  any  individual  case 
should  be  adopted.  Amongst  drugs,  cod  liver  oil  is  the  most  generally 
useful,  and  in  these  cases  it  may  be  combined  with  phosphorus,  T^th  of  a 
grain  of  the  drug  being  added  to  each  dose  of  the  oil. 

Vinum  ferri  (dose  3ss — 3j),  or  syrup  of  the  hypophosphites  (dose 
3ss — 3j)  may  also  be  given.  The  state  of  the  digestive  organs  will 
require  particular  attention,  and  special  care  has  to  be  taken  to  prevent 
the  occurrence  of  constipation. 

Local  Treatment. — It  is  important  to  bear  in  mind  that,  in  the 
early  stages  of  the  disease,  there  is  a  marked  tendency  to  the  spontaneous 
cure  of  the  curvature,  and,  to  facilitate  this,  the  first  essential  is  to  prevent 
the  patient  walking,  and  thus  to  take  the  weight  of  the  body  off  the  feet, 
and  so  to  avoid  increasing  the  curve  mechanically.  Appropriate  general 
treatment  must  not  be  neglected.  In  many  of  the  slighter  cases,  when 
the  patient  is  properly  dieted,  put  under  suitable  hygienic  conditions, 
and  prevented  from  bearing  weight  upon  the  limb  or  from  lying  with 
the  limb  on  its  outer  side  (which  would  increase  the  curve),  the  bones 
undergo  solidification,  and  the  curve  not  only  ceases  to  extend,  but 
disappears  entirely. 

It  is  advantageous  to  employ  massage  and  electricity.  At  the  same 
time  the  limb  may  be  douched  and  attempts  made  to  reduce  the  curvature 


366 


DEFORMITIES 


by  steady  manipulation ;  a  great  deal  can  be  done  by  the  nurse  in  this 
direction.  The  limb  should  be  grasped  at  the  extremities  of  the  curve, 
the  thumbs  applied  opposite  the  point  of  greatest  convexity,  and  the 
bone  may  be  straightened  by  steady  and  gradual  pressure  which  does 
not  cause  the  child  pain. 

In  the  more  advanced  eases,  when  there  is  distinct  bending  of  bones 
which  are  still  so  ft  (as  will  be  the  case  when  the  rickety  condition  is  active), 
the  use  of  splints  and  internal  remedies  will  often  ensure  a  satisfactory 

result,  if  the  child  be  prevented  from  walking. 
We  prefer  a  straight  internal  splint  of  wood, 
slightly  wider  than  the  antero-posterior  diameter 
of  the  leg,  extending  from  the  internal  condyle 
of  the  femur  to  six  inches  beyond  the  sole.  It 
requires  careful  padding  opposite  the  tuberosity 
of  the  tibia  and  the  inner  malleolus,  so  as  to 
avoid  the  possibility  of  ulceration  from  pressure. 
The  splint  is  made  to  extend  well  beyond  the 
foot,  and  not  just  an  inch  or  two  as  is  usually 
recommended,  in  order  to  prevent  the  patient 
putting  the  toes  to  the  ground  ;  when  it  does 
not  project  far  enough,  it  is  possible  for  the 
child  to  walk  about  on  the  points  of  the  toes. 
The  splint  is  firmly  fixed  above  and  below  with 
straps  and  buckles,  and  a  broad  piece  of  elastic 
webbing  may  be  applied  opposite  the  point  of 
greatest  convexity,  so  as  to  draw  the  limb 
gently  inwards  against  the  splint  (see  Fig.  120). 
When  the  curve  is  very  marked,  so  that  there 
is  a  considerable  tendency  for  the  splint  to  slip 
round,  it  is  a  good  plan  to  have  a  light  iron  bar 
screwed  to  the  lower  end  of  the  splint  and 
fastened  to  the  heel  of  the  boot  so  as  to  prevent 
rotation. 

Although   a  great   deal   has   been   written 

about  the  influence  of  splints  of  this  kind  in  straightening  these  curva- 
tures, their  real  function  is  to  prevent  the  deformity  from  becoming 
worse,  and  thus  allow  nature  to  obliterate  it  as  growth  progresses. 
This  point  is  of  the  highest  importance  in  practice,  because,  should  the 
surgeon  be  under  the  impression  that  he  is  able  to  obliterate  the  curve 
by  splints,  he  is  apt  to  apply  so  much  force  as  to  produce  ulceration  at 
the  points  of  greatest  pressure,  namely,  over  the  convexity  of  the  curve 
or  opposite  the  knee  and  ankle.  It  may  be  safely  said  that,  unless  the 
bones  are  so  soft  that  they  can  be  straightened  by  the  hand,  the  application 
of  splints  can  produce  little  alteration.  Massage  and  electricity  (vide 
supra)  should  also  be  employed. 


FIG.  120. — SIMPLE  APPARATUS 
FOR  BOW-LEG.  Uhe  splint  is 
bandaged  in  position  on  the  right 
side ;  on  the  left,  it  is  simply 
fastened  with  straps  and  buckles. 
The  two  splints  are  of  unequal 
length  so  as  to  prevent  the  child 
from  walking. 


CURVED  TIBIA   AND   FIBULA 


367 


The  mechanical  treatment  of  the  acute  anterior  curvature  immediately 
above  the  ankle  is  unsatisfactory,  and  operation  will  be  called  for  in  most 
cases,  after  the  acute  stage  of  the  rickets  has  passed  off.     In  the  mean- 
time the  child  should  be  kept  off  his 
feet  by  means  of  suitable  splints. 

In  eases  of  marked  curvature  when 
the  bones  have  undergone  solidification, 
as  is  usual  in  children  over  the  age  of 
four  or  five,  early  operation  is  advisable. 
The  chance  of  straightening  the  limb 
by  splints  is  extremely  slight,  and  it  is 
a  waste  of  time  and  money  to  persevere 
with  them.  The  exact  nature  of  the 
operation  will  be  determined  by  the 
precise  form  and  extent  of  the  curve ; 
the  seat  of  the  operation  will  also  to 
some  extent  be  determined  by  the 
same  factors.  When  there  is  a  general 
concavity  of  the  tibia  inwards,  division 
of  the  bones  should  be  practised  about 
the  centre  of  the  curve.  When  the 
curve  is  limited  to  either  the  upper  or 
lower  part  of  the  bone,  division  should 
be  practised  opposite  the  point  of 
greatest  curvature.  In  the  antero- 
posterior  curvatures  at  the  lower  end, 
the  bone  should  be  divided  at  the 
acute  angle  formed  by  the  curve. 

Several  points  require  consideration 
in  connection  with  the  operation.  The 
surgeon  may  either  simply  divide  the 
bone,  i.e.  he  may  perform  a  linear 
osteotomy,  or  he  may  remove  a  wedge- 
shaped  portion  from  it.  It  is  also  im- 
portant to  consider  whether  the  fibula 
requires  division  or  not  ;  sometimes 
this  bone  is  so  soft  that  it  can  be  bent 
without  being  broken,  and  at  most  a 
greenstick  fracture  may  be  produced  by 
bringing  the  limb  into  position.  When 

either  of  these  procedures  can  be  carried  out,  it  is  of  considerable  advan- 
tage, as  if  division  of  the  fibula  can  be  avoided,  there  is  only  a  single 
wound,  and  a  fairly  strong  bone  is  left  to  act  as  a  splint  to  the  other. 
When,  however,  the  rickety  condition  has  passed  off  and  the  bones 
have  undergone  complete  consolidation,  and  more  particularly  when 


FIG.  HI. — TRACING  FROM  A  CASK  OF 
CURVATURE  OF  THE  LOWER  END  OF  THB 
TIBIA  TREATED  BY  SIMPLE  SPLINTING.  The 
age  of  the  child  is  shown  upon  the  lines, 
which  indicate  the  long  axis  of  the  foot. 


363 


DEFORMITIES 


the  case  is  one  of  antero-posterior  curvature  at  the  lower  end  of 
the  bone,  it  may  be  necessary  to  divide  the  fibula  as  well  as  the  tibia. 
The  bone  can  be  exposed  at  the  requisite  spot  by  a  small  incision 
over  its  outer  surface  and  divided  with  cutting  pliers  after  the  peri- 
osteum has  been  separated  by  a  rugine.  Removal  of  portions  of  the 
fibula  is  only  called  for  when  the  curve  is  very  extreme  and  the  bones  will 
not  come  straight  until  the  ends  of  the  fibula  overlap  one  another  ;  enough 
must  then  be  removed  to  bring  the  ends  into  contact  without  overlapping. 
The  main  factor  influencing  the  choice  between  linear  osteotomy  and 


FIG.  122. — VARIOUS  FORMS  OF  OSTEOTOMY  OF  THE  TIBIA. 

A.  Simple    Transverse    Linear   Osteotomy.     The    thick    lines    show   the    original 
position  of  the  bone  and  the  line  of  bone  section.     The  dotted  ones  show  the  position  of 
the  fragments  when  the  bone  is  straightened.     It  will  be  seen  that  a  large  gap,  which 
may  lead  to  non-union  is  left  when  the  curve  is  marked. 

B.  Cuneiform  Osteotomy.    It  will  be  seen  from  the  figure  how  the  triangular  gap  is 
converted  into  a  linear  division  when  the  bone  is  straightened. 

C.  Oblique  Osteotomy.    The-  first  figure  shows  the  oblique  method  applied  to  a 
lateral  bending  of  the  bone — in  this  case  a  curvature  outwards — while  the  second  shows 
it  applied  to  an  antero-posterior  curve,  the  upper  border  of  the  figure  being  the  crest  of 
the  tibia.    The  figures  also  show  the  method  of  rotation  after  the  section  has  been  made. 

removal  of  a  wedge  from  the  tibia  is  the  degree  of  curvature  present. 
When  this  is  not  very  great,  linear  osteotomy  will  meet  the  requirements  of 
the  case  ;  when  the  curvature  is  extreme,  and  especially  when  it  is  so 
acute  as  to  form  almost  an  angle,  it  is  advisable  to  remove  a  wedge.  This 
is  particularly  the  case  in  the  antero-posterior  curves  at  the  lower  end  of 
the  bone,  in  which  transverse  division  of  the  tibia  will  not  allow  the  de- 
formity to  be  rectified ;  the  only  procedure  which  makes  this  feasible  is 
the  removal  of  a  wedge  with  the  base  directed  forwards.  In  the  ordinary 
bow-legged  deformity  the  base  of  the  wedge  removed  should  of  course  look 
outwards. 

Cuneiform  osteotomy  of  the  Tibia. — The  operation  is  performed  by 
making  an  incision  down  to  the  bone  along  the  crest  of  the  tibia  over  the 


CURVED  TIBIA  AND  FIBULA 


369 


point  of  greatest  curvature  for  a  distance  that  will  vary  with  the  amount 
of  bone  requiring  removal.  The  periosteum  is  separated  on  each  side  by  a 
rugine,  and  then  a  wedge  of  bone  is  removed  by  means  of  a  chisel ;  a  simple 
method  of  procedure  is  to  use  a  saw  for  marking  out  the  portion  of  bone 
to  be  removed,  and  to  complete  the  division  with  the  chisel.  This 
is  preferable  to  using  the  saw  throughout,  as  there  is  some  danger  of 
injuring  the  structures  of  the  calf  when  the  posterior  surface  of  the  tibia 
is  divided. 

After  enough  bone  has  been  removed  to  allow  the  limb  to  be  brought 
straight,  the  wound  is  stitched  up  and  the  dressings  are  applied.  It  is 
seldom  necessary  to  fasten  the  fragments  together,  but,  in  cases  of  marked 
antero-posterior  bending  just  above  the  ankle,  it  is  sometimes  of  advan- 
tage to  do  this  in  order  to  prevent  the  foot  from  falling  back.  In  these 
cases  also  it  is  sometimes  well  to  divide  the  tendo  Achillis,  which  would 
otherwise  have  a  great  tendency  to  pull  the  heel  back. 


FIG.  123. — METHOD  OF  PUTTING  UP  THE  LIMB  AFTER  OSTEOTOMY  OF  THE  TIBIA. 
For  the  sake  of  clearness  no  dressings  are  shown  applied  to  the  limb.  There  is  one  fairly 
long  pad  (c)  applied  over  the  convexity  of  the  curve,  and  two  small  thick  ones  (a  and  6) 
on  the  opposite  side  of  the  limb,  between  the  spint  and  the  inner  condyle  of  the  femur 
above,  and  the  inner  malleolus  below. 

When  linear  osteotomy  is  preferred  to  the  cuneiform  variety,  it  is  well, 
if  possible,  to  make  the  section  of  the  bone  as  oblique  as  possible,  so  as  to 
get  a  broader  surface  for  union,  and  in  Fig.  122  is  illustrated  a  method  by 
which  this  oblique  section  can  be  so  adapted  to  different  curvatures  as  to 
allow  the  deformity  to  be  reduced  with  the  least  separation  of  the  bony 
surfaces. 

After-treatment.— The  limb  should  be  put  up  on  a  splint,  and  for  this 
purpose  we  generally  employ  a  trough  of  Gooch's  splinting  (see  Fig.  123) 
for  the  first  few  days  until  the  wound  has  healed  and  the  stitches  are 
removed.  The  splint  is  wide  enough  to  surround  rather  more  than  half 
the  limb,  and  extends  from  the  fold  of  the  buttock,  where  it  is  cut  away 
obliquely  from  within  outwards  and  upwards,  to  well  below  the  foot.  A 
portion  should  be  cut  out  opposite  the  heel  so  that  no  injurious  pressure 
shall  be  exerted,  but  in  small  children  this  need  not  be  done,  as  the  padding 
may  be  so  arranged  that  the  heel  is  pushed  somewhat  forward  and  does 
not  press  upon  the  splint.  The  limb  is  made  to  fit  the  splint  by  packing 
pads  of  suitable  size  and  shape  on  each  side  and  behind  the  limb,  which 

B  B 


370  DEFORMITIES 

may  thus  be  fixed  in  any  position  that  is  most  suitable.  Any  desired 
amount  of  inversion  or  eversion  of  the  foot  can  be  obtained  by  graduating 
the  padding ;  generally  speaking,  a  large  long  pad  should  be  applied 
opposite  the  point  of  greatest  convexity  of  the  curve  that  it  is  required 
to  obliterate,  and  smaller  thicker  ones  between  the  ends  of  the  bones  and 
the  sides  of  the  splint.  The  latter  is  then  fastened  round  the  limb  by 
broad  bandages,  and  the  whole  is  laid  upon  an  inclined  plane  to  which 
it  may  be  secured  by  a  bandage. 

In  about  a  week  the  stitches  may  be  removed,  and  a  collodion  dressing 
applied.  Any  additional  correction  of  the  deformity  may  then  be  made, 
if  necessary,  under  an  anaesthetic,  and  the  limb  put  up  in  the  fully  rectified 
position  in  a  plaster  of  Paris  or  silicate  bandage  for  another  week  or 
ten  days;  it  is  of  course  necessary  that  the  foot  should  be  strictly  at 
right  angles  to  the  leg.  As  soon  as  the  wound  has  healed,  the  case  may  be 
treated  as  one  of  a  simple  fracture  in  which  there  is  no  displacement  of  the 
fragments.  The  patient  should  be  kept  in  bed  with  a  firm  sandbag  on 
each  side  of  the  leg.  Twice  a  day  the  leg  is  thoroughly  massaged,  and  at 
the  end  of  four  weeks  sufficient  union  will  be  found  to  have  occurred 
to  prevent  any  recurrence  of  the  deformity.  The  child  may  now  be  allowed 
to  sit  up  wearing  the  simple  splints  recommended  above  for  the  early 
stages  of  curvature,  the  splints  being  removed  night  and  morning  for 
massage.  In  this  way  it  is  possible  to  avoid  the  extreme  muscular  wasting 
which  often  follows  osteotomy  when  the  leg  has  been  encased  for  months 
in  a  rigid  plaster  of  Paris  casing,  and  in  addition,  union  of  the  divided  bone 
takes  place  more  rapidly.  About  six  months  after  the  operation  the 
patient  may  be  allowed  to  walk  without  any  apparatus. 


CHAPTER    XVIII. 
GENU  VALGUM  :  GENU  VARUM  :  GENU  RECURVATUM. 

GENU  VALGUM. 

BY  the  term  genu  valgum  or  knock-knee,  is  understood  a  deformity  of  the 
lower  extremity  in  which  the  leg  is  deflected  outwards,  so  as  to  form  with 
the  thigh  an  angle  which  is  smaller  than  the  normal.  It  may  appear  at 
two  periods  of  life  ;  either  during  the  first  five  or  six  years  of  life  or  during 
adolescence. 

CAUSES. — The  ordinary  form  of  the  affection  arises  spontane- 
ously, but  a  similar  deformity  may  appear  under  other  circumstances. 
For  example,  it  may  follow  some  injury  or  disease  of  the  lower  end  of  the 
femur,  which  destroys  the  outer  part  of  the  epiphyseal  line,  so  that  normal 
growth  takes  place  on  the  inner  side,  but  is  arrested  on  the  outer,  and  the 
leg,  therefore,  becomes  deflected  outwards.  Some  degree  of  genu  valgum 
is  fairly  common  in  association  with  osteo-arthritis  of  the  knee  joint,  and 
it  is  also  met  with  in  connection  with  Charcot's  disease  of  the  knee.  It  is 
also  a  not  infrequent  sequela  of  infantile  paralysis,  and  it  may  result 
from  any  accident  involving  rupture  or  extreme  stretching  of  the  internal 
lateral  ligament  of  the  knee  joint.  It  may  sometimes  arise  after  excision 
of  the  knee,  when  the  patient  _is  allowed  to  get  about  too  soon,  and  the 
weak  union  between  the  bones  yields  and  allows  the  production  of  this 
angular  deformity  ;  another  cause  of  its  occurrence  after  excision  is  that 
the  bone  section  may  have  damaged  the  outer  part  of  the  epiphyseal 
line,  and  have  left  the  inner  part  intact,  so  that  growth  occurs  normally  on 
the  inner  side,  while  it  is  arrested  on  the  outer. 

We  shall  only  deal  here  with  those  forms  of  genu  valgum  which  occur 
spontaneously  in  infants  and  young  adults  without  the  occurrence  of  any 
injury,  operation,  or  paralysis.  There  has  been  considerable  discussion  as 
to  the  nature  of  the  deformity  in  this  variety.  Recent  researches,  in 
particular  the  work  of  Mickulicz,  show  that  there  is  no  change  in  the 
epiphyses  of  the  femur  or  the  tibia  either  in  the  child  or  in  the  young 

37i  BBS 


372  DEFORMITIES 

adult,  and  that  there  is  no  increased  length  in  the  internal  condyle,  and 
no  diminution  in  the  external ;  the  whole  change  apparently  occurs  in  the 
diaphysis  in  the  immediate  neighbourhood  of  the  epiphyseal  line.  It  has 
also  been  shown  that  these  changes  are  not  limited  to  the  femur,  but 
affect  the  tibia  to  a  corresponding  degree,  so  that  in  ah1  cases  of  marked 
genu  valgum  the  bones  of  the  leg  show  a  curvature  as  well  as  the  femur. 
This  is  a  point  of  great  importance  in  treatment. 

The  condition  is  essentially  due  to  a  softening  of  the  bones  in  young 
children,  as  well  as  in  adolescents  ;  in  the  former,  the  disease  seems  to  be 
invariably  of  a  rickety  nature,  whilst  in  young  adults  it  is  not  improbable 
that  this  is  also  the  case,  although  it  is  frequently  impossible  to  find  any 
rickety  change,  except  the  softening  of  the  bone.  Whether  the  disease 
in  adolescence  be  due  to  rickets  or  not,  the  facts  remain  that,  before  it  can 
occur,  the  bones  must  be  soft  enough  to  undergo  bending,  and,  further, 
that  the  curvature  occurs  in  the  diaphysis  immediately  beyond  the 
epiphyseal  line.  The  changes  in  the  femur  consist  of  an  outward  bending 
at  the  lower  end  of  the  shaft,  and  an  extension  downwards  of  the  diaphysis 
on  the  inner  side,  so  that  the  epiphyseal  line  is  altered  in  position  and 
runs  obliquely  from  without,  downwards  and  inwards.  In  the  tibia  the 
change  occurs  in  the  diaphysis  immediately  below  the  epiphyseal  line,  and 
results  in  an  outward  curvature  of  the  bone  at  that  spot.  In  addition  to 
the  alterations  in  the  immediate  neighbourhood  of  the  knee  joint,  certain 
other  changes  are  also  met  with  in  this  condition.  In  young  children 
there  is  a  tendency  to  hyper-extension  of  the  joint,  whilst  the  femur 
becomes  rotated  outwards,  so  that  in  walking  the  foot  may  be  strongly 
everted.  Flat  foot  is  also  a  frequent  accompaniment  of  the  affection  ; 
in  some  cases  it  may  be  the  exciting  cause  of  the  deformity,  the  alteration 
in  the  foot  throwing  the  line  of  transmission  of  the  weight  of  the  body 
somewhat  outwards.  This  diminishes  the  pressure  on  the  inner  part  of 
the  lower  end  of  the  femur,  increases  it  on  the  outer  side,  and  thus  pro- 
duces the  curvature.  The  condition  is  generally  bilateral,  especially  in 
young  children,  although  it  is  generally  worse  in  one  leg  than  in  the 
other. 

TREATMENT. — In  all  rickety  deformities,  there  is  a  tendency 
to  spontaneous  cure  during  the  period  of  growth.  The  number  of  cases 
seen  in  adults  is  much  smaller  than  that  of  the  incipient  ones  seen  in  child- 
hood ;  and  many  cases  of  slight  deformity  seen  in  adult  life  have  been 
severe  in  childhood,  a  partial  cure  having  taken  place  spontaneously. 
This  is  seen  especially  in  the  antero-posterior  curves  of  the  lower  end  of  the 
tibia.  In  the  rickety  cases  the  bones  are  soft  and  bend,  and,  when  the 
pressure  is  taken  off,  the  tendency  is  for  them  to  return  to  their  normal 
shape.  The  bending  may  be  produced  either  by  the  weight  of  the  body 
when  the  child  is  standing  or  by  the  pressure  due  to  a  faulty  position  in 
children  who  have  never  walked. 

The  treatment  therefore  is  partly  general  and  partly  local.     The 


GENU  VALGUM 


373 


general  treatment  must  be  directed  to  the  removal  of  the  cause  which 
produces  softening  of  the  bones,  and  as,  in  the  great  majority  of  cases, 
this  is  rickets,  the  general  treatment  is  that  suitable  for  this  affection  ; 
this  is  dealt  with  fully  in  Vol.  II.  and  has  been  referred  to  in  speaking  of 
bow  legs  (see  p.  363). 

Local  Treatment. — This  will  depend  primarily  upon  the  degree 
of  the  deformity.  Up  to  a  certain  point,  divergence  of  the  legs  is  a  con- 
dition that  may  be  remedied  comparatively  easily  by  manipulations  or 
apparatus  ;  when  it  gets  beyond  that  point,  operative  interference  will  be 
necessary.  The  first  essential  is  to  estimate  the  amount  of  deformity 
present,  and  this  is  best  done  by  making  the  patient  lie  flat  upon  the  back 
upon  a  table  (not  a  yielding  bed),  and  bringing  the  femora  parallel  with 
one  another,  with  the  patellae  looking  directly  forwards  and  the  internal 
condyles  separated  by  about  half  an  inch.  The  distance  between  the 
internal  malleoli  is  then  measured,  and  those  cases  in  which  the  distance 
between  them  does  not  exceed  four  inches  are  reckoned  as  mild  ones 
which  will  get  well  without  operation.  When  the  interval  is  greater, 
the  case  may  be  reckoned  as  bad,  and  when  it  is  six  inches  or  more, 
operative  interference  will  be  required  almost  certainly  before  the 
deformity  can  be  remedied.  In  these  bad  cases  it  will  be  noted  that  the 
patella  no  longer  lies  in  the  inter-condyloid  notch,  but  is  displaced 
outwards. 

Cases  in  which  the  separation  between  the  malleoli  does  not  exceed 
an  inch  and  a  half. — Here  there  is  every  probability  that  the  limbs 
will  become  straight  without  any  special  local  treatment  if  the  child  be 
merely  kept  from  walking,  and  if  proper  attention  be  paid  to  the  general 
treatment.  In  deference  to  the  wishes  of  friends,  however,  it  is  often 
wise  to  employ  some  local  treatment.  The  limb  may  be  massaged  twice 
or  thrice  daily,  and,  during  the  process,  the  nurse  should  fix  the  thigh, 
and  keep  the  knee  extended,  with  the  patella  directed  forwards  and 
should  then  press  the  leg  and  foot  gently  inwards,  and  hold  it  in  this 
position  for  a  few  minutes  at  a  time.  If  this  be  carefully  done,  and  the 
child  prevented  from  walking,  the  deformity  is  most  likely  to  disappear 
without  further  treatment,  but  the  restriction  as  to  walking  must  not  be 
removed  until  the  leg  is  practically  straight  and  until  the  active  period  of 
rickets  has  passed,  until  in  fact  the  child  is  four  or  five  years  old.  It  is 
often  very  difficult  to  prevent  children  from  walking  or  crawling,  and  in 
some  cases  the  general  health  may  even  suffer  from  a  constant  enforcement 
of  the  recumbent  position.  Under  these  circumstances,  the  rule  may  be 
relaxed  to  the  following  extent.  The  child  may  be  allowed  to  go  out  into 
the  sunshine  and  run  about  in  the  fresh  air,  but  all  walking  or  crawling 
about  the  house  should  be  prohibited.  As  soon  as  he  comes  indoors  he 
should  be  made  to  lie  down,  and  the  limbs  should  be  rubbed,  and  the 
manipulations  for  the  rectification  of  the  deformity  indicated  above 
should  be  carried  out. 


374 


DEFORMITIES 


When  the  child  is  allowed  to  be  about  during  the  day  in  the  open  air, 
the  limb  should  be  confined  on  a  splint  at  night.  In  young  children  the 
best  form  is  a  Thomas's  hip  splint,  in  which  an  outside  bar  of  iron  connects 
the  bands  surrounding  the  thigh  and  leg  (see  Fig.  124).  The  splint  is  fixed 
on  in  the  usual  manner,  the  band  around  the  thorax  is  fastened  in  position, 
and  the  trunk  secured  to  the  upper  part  of  the  splint  by  means  of  a  flannel 
bandage.  The  thigh  and  leg  are  then  fastened  to  the  splint,  and  a  broad 
piece  of  elastic  webbing,  well  padded  opposite  the  internal  condyle,  is 
passed  around  the  knee  and  fastened  to  the  outside  iron  band  so  as  to  draw 
the  knee  outwards.  The  knee  must  not  be  allowed  to  become  flexed,  or 
else  the  pressure  is  of  no  avail  in  remedying  the  deformity  ;  care  must 

likewise  be  taken  to  prevent  rota- 
tion of  the  limb  at  the  hip  joint, 
which  would  render  the  outward 
pull  upon  the  knee  ineffectual. 
If,  however,  the  leg  and  thigh  be 
carefully  bandaged  to  the  splint 
before  the  elastic  pressure  is  ap- 
plied and  if  the  bands  of  the 
splint  be  closely  applied  to  the 
limb,  this  is  not  likely  to  occur. 
The  splint  should  be  removed  in 
the  morning,  the  limb  washed 
and  rubbed,  the  knee  manipulated 
as  before,  and  then  the  child 
may  be  allowed  to  crawl  or  play 
about  in  the  sunshine. 

Cases  in  which  there  is  a  sepa- 
ration of  three  or  four  inches 
between  the  malleoli. — The  child 
should  be  kept  off  his  feet,  and 
should  wear  both  day  and  night  a  splint  designed  to  pull  the  knee  out- 
wards ;  the  best  is  an  external  splint  furnished  with  a  band  around  the 
knee  so  applied  as  to  pull  the  latter  outwards.  The  chief  disadvantage 
of  a  splint  of  this  kind  is  that  the  child  generally  manages  to  rotate  the 
leg  outwards,  and  thus  the  band,  which  should  bring  the  knee  against 
the  splint,  is  rendered  ineffectual.  Directly  any  outward  rotation  occurs, 
the  band  ceases  to  act  upon  the  deformity,  and  simply  bends  the  knee. 
Care  should  therefore  be  taken  to  see  that,  whatever  splint  be  applied, 
this  rotation  is  impossible.  In  young  children  the  modification  of 
Thomas's  splint  just  described  answers  very  well,  and  its  action  may 
be  increased  by  prolonging  the  lower  end  of  the  iron  bar  three  inches 
beyond  the  foot  so  as  to  prevent  the  child  from  walking. 

A  splint  more  suitable  for  older  children  is  one  in  which  there  is  an 
outside  iron  running  from  a  pelvic  band  above  to  a  slot  in  the  heel  of  the 


FIG.  124. — THOMAS'S  Hip  SPLINT,  ADAPTED  FOR 
USE  IN  GENU  VALGUM.  This  is  an  ordinary  Thomas's 
hip  splint  to  which  is  added  an  outside  iron  bar  join- 
ing the  lateral  wings  above  and  below  the  knee.  This 
iron  may  be  prolonged  below  the  foot  so  as  to  prevent 
the  patient  from  walking.  (Modified  from  Hoffa.) 


GENU  VALGUM 


375 


boot  below  and  which  therefore  prevents  rotation.     This  necessitates  the 

child  wearing  a  boot  both  day  and  night,  but  this  is  no  great  objection. 

The  knee  is  drawn  outwards  against  the  splint  by  means  of  a  broad 

elastic  sling  (see  Fig.  125). 

Children  are  often  allowed  to  walk  wearing  an    apparatus    which 

allows  the  knee  joint  to  be  bent  and  which,  at  the  same  time,  is  supposed 

to  pull  the  knee  outwards,  but  these  splints  are  inefficient ;  they  are  too 

heavy  for  the  weakly  children  who  have  to  wear  them,  they  are  expensive 

and  they  do  not  exert  much  influence  upon 

the    deformity.       Indeed,     considering    the 

satisfactory  results  of  operative  interference 

and  the  infinitesimal  risk  attaching  to  it,  it 

is   better    to   operate   at   once,  when    it   is 

essential    for    the  child's    comfort    that    he 

should   walk,   and   when   he   cannot   do   so 

without  an  apparatus  of  this  kind. 

For  patients  to  whom  the  expense  of 
these  forms  of  apparatus  is  prohibitive,  a 
simple  wooden  splint  yields  very  fair  results. 
Two  pieces  of  wood  about  two  inches  wide 
and  long  enough  to  extend  from  the  groin 
to  four  inches  below  the  sole  are  padded 
with  tow  or  dressmaker's  cotton-wool  and 
covered  with  some  firm  fabric.  One  of 
these  splints  is  fastened  to  the  inner  aspect 
of  each  limb  with  three  of  the  straps  and 
buckles  usually  used  for  carrying  books  ;  one 
strap  is  placed  around  the  thigh  at  the  upper 
part  of  the  splint,  a  second  just  above  the 
knee  joint,  and  the  third  just  above  the 
ankle  joint ;  the  whole  splint  is  then  further 
secured  by  a  flannel  bandage  applied  from 
below  upwards.  The  object  of  these  splints 
is  to  prevent  the  child  from  walking  or  sitting  with  the  legs  curled  up. 
This  is  usually  quite  sufficient  to  rectify  the  deformity  in  all  but  the 
severest  cases,  and  the  improvement  is  often  very  marked  in  a  few 
weeks.  If  the  splints  do  not  restrain  the  child  and  he  persists  in 
walking  on  their  ends,  they  may  be  made  of  unequal  length. 

The  mechanical  treatment  of  genu  valgum,  whether  in  a  child  or  an 
adult,  must  be  persisted  in  for  a  long  time.  It  must  not  be  given  up 
until  the  active  stage  of  rickets  has  passed  off  and  the  softening  of  the 
bones  has  disappeared  ;  then  there  is  not  much  chance  of  further  increase 
in  the  deformity.  The  active  period  of  rickets  generally  lasts  until  the 
child  is  about  four  years  old,  and  the  deformity  will  certainly  recur  if  the 
apparatus  be  left  off  before  this,  even  though  it  may  have  disappeared 


FIG.  125.— SPLINT  FOR  USE  IN 
GENU  VALGUM.  As  this  necessitates 
the  wearing  of  a  boot,  it  is  more  suit- 
able for  older  children.  It  is  more 
powerful  and  effectually  prevents 
either  flexion  of  the  knee  or  rotation 
of  the  limb.  (Modified  from  Hoffa.) 


376  DEFORMITIES 

under  treatment.  Hence  the  treatment  of  knock-knee  by  rest  and 
mechanical  means  must  be  persevered  with  until  the  child  is  at  least 
four  years  old. 

Cases  in  which  the  separation  between  the  malleoli  is  greater  than  four 
inches,  or  in  which,  in  spite  of  treatment  by  splints,  marked  separation 
exists  after  consolidation  of  the  bones  is  complete. — In  neither  of  these 
groups  can  much  benefit  be  expected  from  mechanical  treatment.  As  a 
rule  it  is  found  that  the  deformity  remains  in  spite  of  prolonged  mechanical 
treatment  and  much  expenditure  of  time  and  money,  and  something 
further  has  to  be  done.  There  is  no  advantage  in  performing  osteotomy 
while  the  bones  are  still  soft  if  the  patient  be  allowed  to  walk  as  soon  as 
union  has  occurred,  because  the  deformity  will  certainly  recur.  Hence, 
if  osteotomy  be  done  before  the  bones  are  firm,  the  patient  must  be 
kept  off  his  feet  after  operation,  and  the  treatment  mentioned  above 
adopted.  At  one  time  we  were  accustomed  to  defer  operation  until 
the  rickety  process  was  at  an  end,  and  consolidation  of  the  bones  had 
occurred ;  now,  however,  we  begin  the  treatment  with  an  osteotomy, 
and  follow  up  the  operation  by  the  treatment  appropriate  for  rickets 
(see  p.  363).  We  did  this  originally  because  of  the  disinclination  of 
parents  to  persist  in  the  use  of  splints  for  a  long  period  as  a  preliminary 
to  operative  treatment ;  as  experience  accumulated,  however,  we  found 
that,  on  the  whole,  the  period  of  treatment  was  shortened,  since  con- 
solidation appears  to  occur  more  rapidly  after  operation,  possibly  as 
a  result  of  the  complete  rest  and  better  feeding.  Should  early  operation 
not  be  employed,  however,  the  treatment  by  splints,  etc.,  described 
above,  is  carried  out,  partly  with  the  view  of  correcting  the  deformity  to 
some  extent,  but  mainly  in  order  to  prevent  it  from  becoming  exaggerated. 
When  the  child  has  reached  the  age  of  four  or  five,  and  there  is  evidence 
that  the  bones  are  becoming  firm,  and  when  there  is  still  a  separation  of 
more  than  four  inches  between  the  malleoli,  it  is  useless  to  persevere 
with  mechanical  treatment,  whilst  operation  furnishes  a  satisfactory 
and  rapid  cure. 

In  young  adults  mechanical  measures  seldom  produce  a  satisfactory 
result,  and  it  is  sad  to  see  these  patients  wearing  cumbrous  apparatus, 
and  spending  much  time  and  money  in  attempts  to  get  cured  of  a  de- 
formity that  can  be  put  right  by  a  simple  operation.  In  young  adults 
suffering  from  genu  valgum,  therefore,  we  would  advise  operation  in 
all  cases  in  which  the  distance  between  the  malleoli  reaches  four  inches. 
It  is  not  necessary  to  wait  for  complete  consolidation  in  them.  This 
generally  occurs  while  the  patient  is  lying  in  bed  after  the  operation, 
and  if  care  be  taken  not  to  allow  the  entire  weight  to  be  borne  upon  the 
limb  too  soon,  and  if  suitable  general  treatment  be  adopted,  there  is  little 
risk  of  the  deformity  recurring. 

Osteotomy. — Various  forms  of  operative  procedure  have  been 
employed  in  these  cases.  Those  in  which  the  bone  is  broken  without 


GENU  VALGUM 


377 


producing  an  external  wound  may  be  dismissed  as  unsuitable  ;  it  is 
impossible  to  gauge  the  amount  of  injury  done,  or  the  exact  seat  of  the 
fracture  produced,  while  there  is  not  the  least  advantage  in  its  use  con- 
sidering the  great  safety  of  the  ordinary  operation.  Amongst  the  open 
operations,  the  following  are  most  frequently  performed :  division  of 
the  femur  just  above  the  epiphyseal  line  (Macewen's  operation)  ;  division 
of  the  tibia  below  the  upper  epiphysis ;  or  division  of  both  femur  and 
tibia  (see  Fig.  126).  From  a  consideration  of  the  pathological  changes 
present,  it  is  evident  that  correction  of  the  deformity  in  bad  cases  can 
only  be  obtained  by  the  combined  operation,  and  it  may  be  laid  down 
as  a  general  rule  that,  when  the  interval  between  the  malleoli  is  as  much  as 
six  inches,  this  procedure  should  be  adopted.  In  the  less  severe  cases, 
however,  good  results  may  be  obtained  by  dividing  either  of  the  bones 


ABC 

FIG.  126.  VARIOUS  FORMS  OF  OSTEOTOMY  FOR  GENU  VALGUM.  A.  Macewen's 
operation.  J5.  A  similar  operation,  the  section  being  made  from  the  outer  side  instead 
of  the  inner.  C.  Division  of  the  tibia  below  its  upper  epiphysis ;  this  may  either  be 
linear  or  cuneiform.  D.  Division  of  both  femur  and  tibia.  (Modified  ftocaHoffa.) 

alone,  and  in  practice  it  is  immaterial  whether  the  femur  or  the  tibia  be 
selected  for  division ;  probably  a  neater  result  is  obtained  by  division 
of  the  tibia.  The  femur,  however,  is  the  bone  most  frequently  divided, 
but  this  operation  (Macewen's)  often  produces  an  unsightly  bowing 
outwards  and  forwards  in  the  lower  third  of  the  bone.  The  best  plan  is 
to  have  a  radiogram  of  the  limb  taken  in  the  position  in  which  the  amount 
of  the  deflection  is  estimated  (supra),  and  this  will  show  whether  the 
femur,  the  tibia  or  both  are  affected  and  to  what  degree.  The  operation 
can  then  be  decided  upon  in  accordance  with  the  information  thus 
obtained. 

Macewen's  Osteotomy.— In  dividing  the  femur  by  Macewen's  method, 
the  section  is  made  from  the  inner  side,  and  the  deformity  is  rectified, 
partly  by  squeezing  together  the  bone  on  the  inner  side  of  the  femur, 
and  partly  by  opening  out  an  angle  on  the  outer  side.  Some  surgeons 
prefer  to  divide  the  bone  partly  across  from  the  outer  side,  and  then  to 
convert  this  incision  into  an  open  angle  by  producing  a  greenstick 


DEFORMITIES 


fracture  on  the  inner  side  ;  this  is  certainly  the  easier  operation,  and  the 
one  that  gives  the  better  rectification  at  the  time. 

The  patient  lies  upon  the  back,  with  the  limb  abducted  and  rotated 
outwards,  and  supported  upon  a  firm  sandbag.  The  hip  and  knee  joint 
should  both  be  flexed.  The  following  description  of  the  operation  is  in 
Macewen's  own  words : 

'  A  sharp-pointed  scalpel  is  introduced  on  the  inside  of  the  thigh  at 
the  point  where  the  two  following  lines  meet,  one  drawn  transversely  a 
finger's  breadth  above  the  superior  tip  of  the  external  condyle,  and  a 

longitudinal  one  drawn  half  an 
inch  in  front  of  the  adductor 
magnus  tendon.  The  scalpel 
here  penetrates  at  once  to  the 
bone,  and  a  longitudinal  in- 
cision is  made,  sufficient  to  ad- 
mit the  largest  osteotome  and 
the  finger  should  the  surgeon 
deem  it  necessary.  Before  with- 
drawing the  scalpel,  the  largest 
osteotome  is  slipped  by  its  side 
until  it  reaches  the  bone. 

'  The  scalpel  is  withdrawn, 
and  the  osteotome,  which  was 
introduced  longitudinally,  is  now 
turned  transversely  in  the  direc- 
tion required  for  the  osseous 
incision.  In  turning  the  osteo- 
tome, too  much  pressure  must 
not  be  exerted,  lest  the  peri- 
osteum be  scraped  off.  It  is 
then  convenient  to  pass  the  edge 
of  the  osteotome  over  the  bone 
until  it  reaches  the  posterior  in- 
ternal border,  when  the  entire 
cutting  edge  of  the  osteotome  is 

applied,  and  the  instrument  is  made  to  penetrate  from  behind  forwards, 
and  towards  the  outer  side. 

'  After  completing  the  incision  in  that  direction,  the  osteotome  is  made 
to  traverse  the  inner  side  of  the  bone,  cutting  it  as  it  proceeds,  until  it  has 
divided  the  uppermost  portion  of  the  internal  border,  when  it  is  directed 
from  before  backwards,  towards  the  outer  posterior  angle  of  the  femur. 
'  In  cutting  on  these  lines,  there  is  no  fear  of  injuring  the  femoral 
artery.  The  bone  may  be  divided  without  paying  heed  to  this  order  of 
procedure,  but  it  is  better  that  the  operator  should  have  a  definite  plan 
in  his  mind,  so  that  he  may  be  certain  as  to  what  has  been  divided,  and 


FIG.  127. — INCISION  FOR  MACEWEN'S  OSTEOTOMY 
FOR  GENU  VALGUM.  The  thick  line  is  the  incision, 
the  dotted  lines  the  guides  for  fixing  it. 


GENU  VALGUM 


379 


what  remains  to  be  done.  The  writer  is  persuaded  that  accidents  have 
happened  by  not  paying  attention  to  this.  In  using  the  osteotome,  the 
left  hand,  in  which  it  is  grasped,  ought  to  give,  after  each  impulse  supplied 
by  the  mallet,  a  slight  movement  to  the  blade— not  transversely  to  its 
axis,  but  longitudinally— so  as  to  prevent  any  disposition  to  fixity  which 
it  might  assume. 

'  After  the  inner  portion  of  the  bone  is  divided,  a  finer  instrument 
may  be  slipped  over  the  first,  which  is  then  withdrawn  ;  and  even  a  third, 
if  necessary,  may  take  the  place  of  the  second,  when  the  outer  portion 
of  the  bone  comes  to  be  divided.  Whether  one  or  more  osteotomes  be 
used  depends  much  on  the  resistance  met  with.  If  the  tissue  is  yielding, 
one  may  suffice ;  if  hard  or  brittle,  two  or  three  will  effect  the  division 
more  easily,  and  with  less  risk  of  breaking  or  splitting  the  bones  longi- 
tudinally. In  the  adult,  the  dense  circumferential  layer  of  bone  resists 
the  entrance  of  the  osteotome  at  the  outset,  but  several  strokes  cause 
the  instrument  to  penetrate  this  superficial  dense  portion,  when  it  will 
pass  easily  through  the  cancellated  tissue. 

'  After  a  little  experience,  the  surgeon  recognises,  by  touch  and  sound, 
when  the  osteotome  meets  the  hard  layer  on  the  outer  aspect  of  the  bone. 
If  it  be  considered  desirable  to  notch  or  penetrate  this  outer  dense  part 
of  the  bone,  in  doing  so  the  osteotome  ought  to  be  grasped  firmly  by  the 
left  hand,  the  inner  border  of  the  hand  resting  on  the  limb,  so  as  to  check 
instantly  any  impetus  which  may  be  considered  too  great.  It  is  better 
to  snap  or  bend  this  layer  than  to  cut  it. 

'  When  the  instrument  is  to  be  altered 
in  position,  it  ought  not  to  be  pulled  out 
in  the  ordinary  way,  as  it  is  then  liable 
to  be  removed  from  the  wound  in  the 
soft  parts,  as  well  as  from  the  bone. 
Instead,  let  the  left  hand,  with  its  inner 
border  resting  on  the  limb,  grasp  the  in- 
strument, while  the  thumb  is  pressed 
under  the  ridge  afforded  by  the  rounded 
head,  and  gently  lever  the  osteotome 
outwards  by  an  extension  movement  of 
the  thumb  (see  Fig.  128).  In  this  way 
the  movement  may  be  regulated  with 
precision.  It  is  desirable  to  complete 
all  the  work  intended  by  the  osteotome 
before  removing  it  from  the  wound. 

'  When  the  operator  thinks  that  the 
bone  has  been  sufficiently  divided,  the 
osteotome  is  laid  aside  and  a  sponge 

saturated  in  i  in  40  carbolised  watery  solution  is  placed  over  the  wound. 
While  the  surgeon  holds  the  sponge,  he,  at  the  same  time,employs  that  hand 


FIG.  128. — METHOD  OF  HOLDING  MAC- 
EWEN'S  OSTEOTOME.  The  instrument, 
grasped  in  the  hand,  is  steadied  by  resting 
the  ulnar  border  of  the  hand  upon  the 
thigh,  and  the  thumb  pressed  beneath  the 
head  of  the  chisel  serves  to  lever  it  gently 
out  when  it  is  desired  to  disengage  it. 


380 


DEFORMITIES 


as  a  fulcrum  ;  with  the  other  he  grasps  the  limb  lower  down,  using  it  as  a 
lever,  and  jerks  if  the  bone  be  hard,  or  bends  slowly  if  the  bone  be  soft,  in 
an  inward  direction,  when  the  bone  will  snap  or  bend  as  the  case  may  be.' 
An  Esmarch's  bandage  is  not  necessary  during  the  operation,  and  no 
bleeding  points  require  ligature.  The  line  of  section  is  everywhere  above 
the  ligaments  of  the  joint,  and  no  damage  is  likely  to  be  done  to  the 
popliteal  or  femoral  vessels,  which  are  well  out  of  the  way  of  the  osteotome, 
partly  on  account  of  the  flexion  of  the  knee,  and  partly  by  observing 
the  directions  given  for  the  division  of  the  bone.  The  only  artery  at  all 
likely  to  be  divided  is  the  anastomotica  magna,  but  that  generally  lies 
above  and  behind  the  incision.  The  superior  internal  articular  artery  is 
also  avoided  if  the  above  directions  be  observed.  It  is  rarely  necessary 
to  enlarge  the  wound  in  order  to  tie  bleeding  points  ;  there  is,  however,  no 
objection  to  doing  so,  should  it  be  necessary.  Any  vessel  divided  will 
generally  stop  bleeding,  partly  from  its  own  contraction  and  partly  as  the 
result  of  pressure. 

There  are  some  points  in  the  operations  which  deserve  special  atten- 
tion. It  is  well  to  employ  Macewen's  osteotome  (see  Fig.  129),  which 
differs  from  the  ordinary  chisel  in  that  its  cutting 
edge  is  bevelled  on  both  sides  instead  of  only  on 
one ;  a  chisel  is  apt  to  jam  in  the  bone  instead  of 
dividing  it  evenly.  In  young  children  the  osseous 
section  may  be  completed  with  a  single  osteotome, 
but  in  adults  it  is  advisable  to  have  two  instruments 
of  different  size ;  should  the  larger  instrument 
become  locked,  it  can  be  withdrawn  and  a  smaller 
one  slipped  into  its  place  and  the  section  completed. 
The  larger  osteotome  should  be  about  two-thirds  to 
three-quarters  of  an  inch  wide,  the  smaller  about 
half  an  inch.  When  dividing  the  bone  from  the 
inner  side,  an  endeavour  must  be  made  to  keep  the 
line  of  section  parallel  with  that  of  the  epiphysis,  and 
therefore  it  should  not  be  transverse  to  the  long 
axis  of  the  lower  extremity.  As  a  result  of  the 
displacement  of  the  epiphyseal  line,  which  is  always 
present  in  genu  valgum,  the  chisel  will  become 
buried  in  the  external  condyle  if  it  be  held  trans- 
versely to  the  long  axis  of  the  limb,  and  may 
seriously  damage  the  epiphyseal  line. 

Osteotomy  through  an  Incision  on  the  Outer  Surface  of  Thigh. — Some 
surgeons  prefer  to  divide  the  bone  from  the  outer  side  of  the  limb,  and 
we  most  frequently  do  this  operation  as  it  somewhat  facilitates  the 
rectification  of  the  deformity.  The  incision  should  be  made  just  above 
the  external  condyle,  and,  after  all  the  structures  have  been  divided 
down  to  the  bone,  the  osteotome  is  slipped  in  along  the  blade  of  the 


FIG.  129. — MACEWEN'S 
OSTEOTOME. 


GENU  VALGUM  38i 

knife  and  then  turned  transversely  to  the  long  axis  of  the  femur.  The 
line  which  the  osteotome  should  follow  runs  obliquely  downwards 
and  inwards ;  it  must  not  be  directed  far  enough  downwards  to  injure 
the  epiphyseal  line.  It  is  generally  best  to  make  the  osteotome  cut 
through  about  half  of  the  cancellous  bone  in  the  centre  of  the  diaphysis 
first  of  all ;  then  it  should  be  withdrawn  somewhat  and  made  to  divide 
the  dense  anterior  surface,  and  finally  it  is  made  to  divide  the  dense  bone 
on  the  posterior  aspect.  All  these  incisions  should  be  carried  about 
half  way  through  the  bone,  when  the  osteotome  may  be  withdrawn,  a 
sponge  placed  over  the  wound,  and  the  remainder  of  the  bone  fractured 
by  bending  the  leg  inwards. 

Osteotomy  of  the  Tibia. — The  best  plan  is  to  make  a  vertical  incision 
commencing  at  the  tubercle  and  running  downwards  along  the  crest  for 
about  an  inch.  This  incision  should  be  carried  down  to  the  bone,  which 
is  divided  transversely  with  an  osteotome,  special  care  being  taken 
to  see  that  its  inner  side  is  cut  through  completely.  The  leg  is  then 
brought  forcibly  inwards,  and,  if  sufficient  rectification  cannot  be  obtained 
in  this  way,  the  limb  may  be  bent  outwards  again  so  as  to  fracture  the 
outer  side  completely,  when,  on  bringing  the  limb  inwards  once  more, 
rectification  can  be  obtained  easily. 

Osteotomy  of  the  Femur  and  Tibia  combined. — The  best  rectification  is 
obtained  by  dividing  both  the  tibia  and  the  femur,  and  in  bad  cases 
this  is  necessary  to  ensure  a  satisfactory  result.  It  is  a  matter  of 
opinion  whether  the  two  bones  should  be  divided  simultaneously  or 
at  intervals.  We  are  inclined  to  think  that  it  is  better  to  perform 
the  operation  in  two  stages ;  in  the  first  the  tibia  is  divided,  and  in 
the  second,  after  the  lapse  of  about  six  weeks,  the  femur.  If  the 
operations  be  performed  in  this  order  there  is  less  danger  at  the  second 
operation  of  re-fracturing  the  bone  divided  at  the  first,  whilst  a 
better  rectification  can  be  obtained  if  one  bone  be  allowed  to  undergo 
consolidation  before  the  second  is  divided. 

After-treatment. — The  small  wound  should  be  sutured,  a  dressing 
applied,  the  limb  brought  straight  and  put  upon  a  splint.  We  use  a 
roll  of  Gooch's  splinting  properly  padded  ;  the  method  of  cutting  it  has 
already  been  referred  to  (see  p.  369),  but  in  the  cases  under  consideration  it 
is  well  to  cut  away  a  space  for  the  heel  so  as  to  obviate  all  fear  of  pressure 
upon  the  os  calcis.  A  large  pad  must  be  put  over  the  internal  condyle, 
and  others  over  the  outer  side  of  the  foot  and  ankle,  so  as  to  press  the 
leg  inwards.  Another  pad  must  be  placed  in  front  of  the  knee  so  as 
to  prevent  flexion  of  the  joint  (see  Fig.  130).  After  the  splint  has  been 
applied,  the  limb  should  be  laid  upon  an  inclined  plane  or  a  large  pillow, 
so  that  the  foot  is  well  raised. 

It  is  a  common  practice  to  apply  a  plaster  of  Paris  bandage  at  this 
stage,  but  this  has  the  disadvantage  that  great  muscular  wasting  and 
laxity  of  the  ligaments  is  commonly  found  when  the  bandage  is  removed. 


DEFORMITIES 


It  seems  reasonable  to  treat  an  osteotomy  as  an  ordinary  fracture,  and 
therefore  ordinary  splints  will  be  found  sufficient  to  keep  the  limbs  steady 
after  the  wound  has  healed  and  the  sutures  have  been  removed,  especially 


FIG.  130. — LIMB  PUT  UP  IN  SPLINT  AFTER  OSTEOTOMY  FOR  GENU  VALGUM.  The  large 
pad  (a)  over  the  inner  condyle  on  the  one  side,  and  the  two  thick  ones  (6)  and  (c)  over  the 
outer  malleolus  and  the  great  trochanter  respectively,  on  the  other  side,  are  shown.  The 
large  pad  over  the  front  of  the  knee  to  prevent  flexion  is  not  shown,  while,  for  the  sake 
of  clearness,  the  dressing  to  the  osteotomy  wound  has  been  omitted. 

as  the  fractured  surfaces  are  broad,  the  line  of  division  transverse,  and 

the  periosteum  often  intact  in  places. 

At  the  the  end  of  ten  days,  the  splints  should  be  removed  at  least 

once  daily  for  massage,  and  the  knee  joint  should  be  moved  passively 

at  the  end  of  a  fortnight.  In  a  month 
from  the  operation,  the  splints  may  be  left 
off,  and  the  child  allowed  to  move  the 
legs  in  bed.  No  walking,  sitting  or  stand- 
ing should  be  allowed  for  at  least  six 
weeks  from  the  time  of  operation  and  only 
then  should  the  rickety  condition  of  the 
bone  have  passed  away  completely. 

When  the  osteotomy  has  been  done 
upon  a  young  adult  in  whom  there  is  some 
doubt  as  to  whether  the  bones  have  be- 
come consolidated,  it  is  well  for  the 
patient  after  the  operation  to  wear  some 
form  of  apparatus  to  exert  pressure  upon 
the  deformity  ;  this  may  consist  of  an 
outside  iron  fastened  to  the  pelvis  above 
and  the  heel  of  the  boot  below,  and  fur- 
nished with  hinges  opposite  the  hip,  knee, 
and  ankle  joints  (see  Fig.  131) ;  it  is  gene- 
rally furnished  with  a  band  or  sling  to  draw 
the  knee  outwards  against  the  iron.  This 

apparatus  can  be  made  of  light  material  and  should  be  worn  for  six 

months  after  the  operation. 

Those  forms  of  genu  valgum  arising  in  connection  with  diseases  other 

than  rickets  must  have  the  primary  cause  treated  on  the  lines  appropriate 

for  the  treatment  of  the  particular  disease  to  which  they  are  due.     Should 


FIG.  131. — OUTSIDE  IRONS  FOR  USE 
AFTER  OPERATION  FOR  GENU  VALGUM  IN 
ADULTS.  (Erichsen.) 


GENU  VARUM  383 

genu  valgum  occur  after  excision  of  the  knee,  the  choice  will  lie  between  a 
fresh  excision,  or  Macewen's  operation  ;  in  most  cases  the  latter  is  a  less 
severe  and  an  equally  satisfactory  method.  Should  genu  valgum  occur  in 
connection  with  infantile  paralysis,  the  usefulness  of  the  limb  will  have  to 
be  taken  into  consideration  ;  in  some  cases  it  may  be  found  best  to  perform 
arthrodesis  of  the  knee  joint,  so  as  to  give  the  patient  a  firm  and  fixed 
point  of  support,  whilst  in  others,  in  which  the  muscles  are  fairly  healthy, 
a  Macewen's  operation,  or  any  of  the  other  operative  procedures  which  we 
have  mentioned,  may  be  employed. 

GENU  VARUM. 

This  condition  is  the  converse  of  the  one  just  described,  the  lower  part 
of  the  thigh  and  leg  being  bowed  outwards  so  that  the  two  limbs  form  an 
ellipse,  or,  in  severe  cases,  almost  a  circle  when  the  feet  are  placed  together. 
The  affection  is  usually  due  to  rickets,  although  a  somewhat  similar 
deformity  may  occur  after  excision  of  the  knee,  from  damage  done  to 
the  inner  side  of  the  epiphyseal  line  ;  it  is  also  found  in  those  who  have 
habitually  to  assume  certain  positions,  such  as  grooms,  etc.,  who  are 
constantly  riding.  If  the  patient  be  quite  young  when  the  deformity  starts, 
it  may  attain  a  very  marked  degree  ;  when  it  originates  in  adult  life,  how- 
ever, it  is  seldom  serious  enough  to  call  for  active  treatment. 

The  patient  usually  walks  with  the  toes  turned  in,  and  in  bad  cases 
the  patella  is  dislocated  inwards.  The  condition  is  generally  bilateral, 
although  sometimes  children  suffer  from  genu  valgum  on  the  one  side 
and  genu  varum  on  the  other.  In  these  cases  the  deformity  has  been 
supposed  to  be  due  to  the  child  always  being  carried  upon  one  arm,  so 
that  the  legs  are  pressed  towards  each  other  ;  one  limb  is  thus  forced  into 
a  condition  of  varus,  and  the  other  into  a  condition  of  valgus. 

TREATMENT. — In  the  milder  cases  splints  should  be  applied  to 
the  inner  side  of  the  leg  and  the  patient  kept  off  his  feet,  while  at  the  same 
time  the  general  treatment  suitable  for  rickets  should  be  employed.  In 
the  severer  cases,  and  in  those  in  which  the  bones  have  become  consoli- 
dated, osteotomy  is  necessary.  Of  the  orthopaedic  apparatus  the  best  is 
an  internal  splint  which  extends  from  the  perineum  to  well  beyond  the 
foot,  and  is  thickly  padded  opposite  the  ankle.  This  splint  should  project 
two  inches  at  least  below  the  toes  when  "the  latter  are  pointed,  so  as  to 
prevent  any  possibility  of  the  child  walking  upon  tip-toe. 

In  the  more  advanced  cases,  and  in  those  in  which  the  active  stage  of 
rickets  has  passed  off,  operative  interference  is  often  desirable.  Frac- 
ture of  the  bones  by  means  of  osteoclasts  is  not  to  be  recommended,  for 
the  exact  position  and  nature  of  the  fracture  cannot  be  accurately  gauged 
and  considerable  damage  may  be  done  to  the  soft  parts  and  to  the  liga- 
ments of  the  knee  joint.  The  only  operative  treatment  to  be  recom- 
mended is  osteotomy,  and  when  the  deformity  is  very  marked,  the  bones 


384  DEFORMITIES 

may  require  to  be  divided  at  more  than  one  spot.  Division  of  the  tibia 
is  more  important  than  division  of  the  femur,  and  the  bone  should  be 
cut  through  just  below  the  knee.  The  fibula  is  bent  or  broken  ;  if  it  be 
too  firm,  it  may  be  divided,  but  as  a  rule  it  yields  readily. 

The  division  of  the  tibia  is  best  done  by  an  oblique  osteotomy.  The 
bone  is  exposed  by  a  vertical  incision  over  the  crest,  and  chiselled  through 
obliquely  from  above  downwards  and  backwards  (see  Fig.  122)  ;  it  is 
then  bent  into  position.  It  is  often  necessary  also  to  divide  the  tibia 
lower  down  at  the  point  of  greatest  curvature,  and  this  may  be  done  at 
the  same  operation.  In  very  bad  cases  it  may  be  even  necessary  to  divide 
the  bone  a  third  time  just  above  the  ankle  joint  before  the  deformity 
can  be  rectified  satisfactorily.  The  limb  should  be  put  up  in  Gooch's 
splint  (see  p.  382),  and  the  after-treatment  is  similar  to  that  in  cases  of 
genu  valgum  (see  p.  381). 

In  bad  cases  it  will  also  be  found  necessary  to  divide  the  femur  at  a 
later  date.  The  osteotomy  should  be  practised  immediately  above  the 
lower  end,  but  a  second  one  may  be  required  higher  up  the  limb  should  the 
curvature  be  extreme.  In  bad  cases  several  osteotomies  may  have  to  be 
done  before  the  bones  can  be  got  satisfactorily  straight ;  Macewen  has 
even  done  as  many  as  ten  in  one  patient.  These  bad  cases,  however,  are 
much  less  common  than  they  were.  Two  or  even  three  osteotomies  may  be 
carried  out  at  the  same  time,  but,  when  several  have  to  be  performed,  it 
is  better  to  do  them  at  intervals,  so  as  to  allow  union  to  occur  in  one 
fracture  before  the  next  is  made.  Should  the  bone  be  divided  in  several 
places  at  the  same  time,  there  is  a  risk  of  the  fragments  not  uniting  pro- 
perly, or  if  they  do,  it  is  difficult  to  insure  that  they  unite  in  perfect 
position. 

GENU  RECURVATUM. 

This  condition  is  usually  congenital  and  is  comparatively  rare ;  in  it 
the  leg  is  hyper-extended  at  the  knee-joint.  It  is  met  with  in  connection 
with  congenital  dislocation  of  the  knee,  and  sometimes  it  occurs  apparently 
from  stretching  of  the  posterior  ligaments  of  the  joint.  It  is  occasionally 
met  with  as  the  result  of  infantile  paralysis,  and  it  may  occur  in  con- 
nection with  diseases  in  which  the  patients  have  been  kept  on  their  backs 
for  a  long  time,  for  instance,  long-standing  tuberculous,  hip-joint  disease, 
or  spinal  disease.  It  is  not  at  all  uncommon  in  Charcot's  disease. 

TREATMENT. — The  congenital  cases  are  usually  the  only  ones 
which  call  for  vigorous  treatment ;  the  deformity  is  seldom  excessive  in 
the  others  and  can  generally  be  rectified  by  putting  up  the  limb  for  a  pro- 
longed period  in  a  slightly  flexed  position  and  then  employing  an  apparatus 
furnished  with  a  hinge  opposite  the  knee  joint,  fitted  with  a  stop  to  pre- 
vent hyper-extension. 

In  the  congenital  cases,  however,  it  is  often  very  difficult  to  obtain  a 


GENII  RECURVATUM  385 

satisfactory  result.  In  them  the  patella  is  often  absent  and  in  any  case 
it  is  small.  The  treatment  should  be  directed  to  straightening  the  knee 
first,  and  afterwards  an  attempt  should  be  made  to  obtain  flexion  by  the 
use  of  apparatus.  A  posterior  splint  is  fixed  to  the  thigh  reaching  down 
as  far  as  the  upper  part  of  the  popliteal  space,  and  the  limb  is  laid  upon 
an  inclined  plane  which  terminates  just  above  the  knee.  Extension  by 
weight  and  pulley  is  then  applied  to  the  limb.  At  first  the  extension 
should  be  in  the  line  of  the  thigh,  so  as  merely  to  stretch  the  ligaments, 
but  in  two  or  three  weeks  the  pulley  may  be  gradually  lowered  so  as  to 
produce  an  increasing  amount  of  flexion,  the  thigh  remaining  fixed  in  the 
elevated  position. 

In  very  bad  cases  all  attempts  to  obtain  flexion  may  fail ;  they 
must  not  be  too  energetic,  as  otherwise  a  true  anterior  dislocation  of 
the  leg  may  occur.  When  the  muscles  and  ligaments  are  shortened, 
only  operative  interference  will  overcome  the  trouble ;  this  consists  in 
lengthening  the  quadriceps  extensor  through  a  curved  incision  with  its 
convexity  upwards  about  four  inches  above  the  knee  joint.  A  flap  is 
turned  down,  and  the  muscle  is  divided  in  a  V-shaped  or  zig-zag  manner, 
by  the  method  described  for  lengthening  muscles  (see  Vol.  II.).  At  the 
same  time  all  tense  fibrous  structures  interfering  with  flexion  of  the  limb 
are  divided  by  a  tenotomy  knife. 

The  treatment  is  a  prolonged  one,  and  when  the  patient  begins  to 
walk,  he  must  be  fitted  with  an  apparatus  designed  to  prevent  over-exten- 
sion at  the  knee  joint.  This  has  irons  running  down  both  sides  of  the 
thigh  and  leg,  fastened  to  a  pelvic  band  above  and  the  heel  of  the  boot 
below,  and  has  joints  opposite  the  hip,  knee  and  ankle  joints ;  the  knee 
joint  hinge  is  furnished  with  a  stop  to  prevent  over-extension. 


c  c 


CHAPTER    XIX. 
CURVATURES  OF  THE  NECK  OF  THE  FEMUR. 

CERTAIN  deformities  result  from  alterations  in  the  normal  curvatures 
of  the  neck  of  the  femur  and  are  generally  divided  into  two  groups  called 
respectively  Coxa  Vara  and  Coxa  Valga. 

COXA  VARA. 

CAUSES. — This  deformity  is  met  with  at  two  periods  of  life;  in 
infants  or  young  children  of  three  or  four  and  in  young  adults 
between  the  ages  of  thirteen  and  eighteen.  It  is  said  that  the  affection  is 
sometimes  congenital.  There  is  considerable  uncertainty  as  to  the  exact 
etiology  of  the  disease  ;  it  is  possible  that  the  deformity  occurs  in  infants 
as  the  result  of  some  malposition  in  utero,  as  it  is  difficult  to  account  for 
it  on  the  ground  of  any  faulty  position  assumed  by  the  child  while  lying 
down  or  being  carried  in  arms.  There  is  no  doubt,  however,  that  in  the 
great  majority  of  cases  the  deformity  in  young  children  results  from 
softening  of  the  bones  due  to  rickets.  It  is  also  highly  probable  that  a 
large  number  of  cases  in  young  adults  owe  their  origin  to  the  condition 
that  goes  by  the  name  of  '  rachitis  adolescentium.'  In  some  of  the  adult 
cases,  however,  no  signs  of  rickets  are  to  be  traced,  and  these  have  been 
attributed  to  rheumatoid  arthritis,  to  osteitis,  or  to  other  causes  ;  the 
affection  may  certainly  supervene  upon  a  mild  attack  of  rheumatism. 
The  deformity  in  adults  generally  occurs  'n  those  whose  occupations 
involve  continuous  and  prolonged  standing  or  carrying  of  heavy  weights. 
By  some  it  is  held  that  the  disease  is  more  common  in  young  adults  than 
in  infants,  but  this  is  very  doubtful ;  certainly,  since  our  attention  has 
been  directed  to  the  point,  we  have  found  a  large  number  of  cases  in 
young  rickety  children.  Indeed  careful  examination  of  rickety  children 
with  knock-knees  will  show  a  certain  amount  of  curvature  of  the  neck  of 
the  femur  in  the  majority  of  cases.  This  can  possibly  be  explained  as  a 
deformity  compensatory  to  the  knock-knees,  in  which  condition  there  is 

386 


COXA   VARA 


387 


a  lateral  curve  of  the  whole  limb  with  its  convexity  inwards.  Such  a 
deformity  is  much  more  inconvenient  to  the  patient  than  an  antero- 
posterior  curve,  and  hence  the  limb  tends  to  become  rotated  outwards. 
The  rotation  is  at  first  simply  due  to  muscular  action,  but,  being  main- 
tained, the  soft  bone  bends  and  a  definite  curvature  of  the  neck  of  the 
femur  follows.  Alterations  in  the  neck  of  the  femur  are  sometimes  met 
with  after  fractures  in  that  region  and  are  then  termed  '  traumatic 
coxa  vara.'  These  cases  are  dealt  with  in  connection  with  fractures 
(see  Vol.  II.). 

PATHOLOGICAL  CHANGES.— The  direction  of  the  abnor- 
mal curvature  in  the  neck  of  the 
femur  is  not  invariably  the  same, 
but  it  is  generally  such  as  to  pro- 
duce outward  rotation  of  the  lower 
limb.  The  angle  formed  by  the 
neck  with  the  shaft  of  the  femur 
is  always  diminished,  and  the  great 
trochanter  is  therefore  elevated  and 
the  limb  shortened.  Generally  also 
there  is  a  bowing  forward  of  the 
neck  of  the  bone  so  that  the  tro- 
chanter is  thrown  too  far  back- 
wards and  external  rotation  of  the 
limb  results  (see  Fig.  132). 

As  seen  in  young  children,  the 
affection  generally  has  the  follow- 
ing characters  :  the  trochanter  is 
raised  above  Nelaton's  line  and 
there  is  marked  outward  rotation 
of  the  whole  lower  extremity.  The 
limits  through  which  the  limb  can 
be  rotated  are  smaller  than  normal, 
for,  while  the  range  of  outward 
rotation  is  considerably  increased, 

that  of  internal  rotation  is  proportionately  more  diminished.  The  result 
is  that,  when  the  child  lies  flat  upon  the  bed  and  the  limb  is  rotated 
inwards  as  far  as  it  will  go,  the  patella  at  best  can  only  be  made  to  look 
directly  forwards  and  cannot  be  directed  inwards  at  all ;  indeed,  in  the 
severe  cases,  even  this  amount  of  inward  rotation  cannot  be  effected. 
On  the  other  hand,  the  limb  can  be  rotated  outwards  until  the  patella 
looks  almost  directly  backwards.  There  is  also  considerable  alteration 
in  the  range  of  adduction  and  abduction  ;  when  outward  rotation  is 
marked,  abduction  to  the  normal  extent  is  impossible,  and  the  power 
of  flexion  may  also  be  interfered  with  unless  the  limb  be  in  the  abducted 
position.  If,  however,  the  limb  be  abducted  and  rotated  outwards,  full 

c  c  2 


Fie.    132.— COXA  VARA.    Showing  the  typical 
deformity  of  the  neck  of  the  femur. 


388 


DEFORMITIES 


flexion  can  be  obtained,  and  the  patient  may  actually  be  able  to  make 
the  feet  meet  behind  the  head.  The  feet  are  frequently  kept  rotated 
outwards  at  right  angles  to  the  antero-posterior  plane  of  the  body  with 
the  knees  somewhat  bent,  and  the  child  can  neither  walk  nor  stand 
upright. 

When  the  affection  is  met  with  in  adults,  in  addition  to  the  deformity, 
it  is  common  to  find  complaints  of  a  sensation  of  fatigue  in  the  early 
stages  of  the  affection,  and  of  pain  about  the  hip-joint,  which  becomes 
more  severe  as  the  disease  progresses.  Later  on,  the  patient  begins  to 
limp,  and  ultimately  he  experiences  difficulty  in  stooping,  and  notices 
that  the  movements  of  the  hip-joint  are  restricted  and  abnormal.  If 
the  case  be  left  to  itself  the  final  result  is  that  the  bone  undergoes 
consolidation  in  the  faulty  position  and  the  deformity  is  thus  permanent  ; 
the  patient  is  compelled  to  limp  about  with  the  feet  turned  out  and  suffers 
considerably  from  interference  with  the  movement  of  the  hip-joint. 

TREATMENT.— In  Young  Children.— While  the  child  is  quite 
young  and  the  bones  are  very  soft,  an  attempt  should  be  made  to  rectify 
the  abnormal  curves  by  means  of  extension  and  manipulation.  Most 
of  the  milder  cases  in  young  children  can  be  cured  by  simple  extension, 
the  leg  being  put  up  in  a  position  of  moderate  abduction.  Indeed  rest 
in  bed  for  several  weeks  will  sometimes  produce  great  improvement, 
without  the  use  of  any  extension. 

Mechanical. — It  is  not  easy  to  devise  an  apparatus  to  maintain 
steady  pressure  upon  the  bone  in  a  direction  such  as  to  restore  the  normal 
curvature  of  its  neck,  but  the  following  arrangement  (see  Fig.  133)  has 

proved  very  successful  in  our 
hands.  A  strip  of  malleable 
iron  of  suitable  length  is  ap- 
plied along  the  back  of  each 
lower  limb.  Each  strip  should 
reach  from  the  centre  of  the 
thigh  above  and  should  be  ac- 
curately adapted  to  the  middle 
line  of  the  back  of  the  thigh 
and  the  calf,  being  bent  round 
behind  the  heel  and  up  along 
the  centre  of  the  sole,  project- 
ing for  several  inches  beyond 
the  tips  of  the  toes  and  end- 
ing there  in  a  hook  (a). 
Opposite  the  under  surface 
of  each  heel  there  is  a  pivot 
(b)  over  which  passes  the 

perforated  end  of  a  transverse  bar  (c)  which  can  be  lengthened  or 
shortened  at  will,  and  from  the  centre  of  which  extension  of  both 


FIG.  133. — EXTENSION  APPARATUS  FOR  COXA  VARA.  The 
anterior  ends  of  the  foot-pieces  are  approximated  by  the 
india-rubber  springs  attached  to  the  hooks  a.  The  abduc- 
tion is  regulated  by  the  transverse  bar ;  the  limbs  can  be 
approximated  or  separated  by  passing  the  pivots  b  through 
the  different  holes  in  the  transverse  bar  c.  These  holes  are 
large  enough  to  allow  the  limb  to  rotate  inwards  easily 
when  in  the  abducted  position.  Extension  is  made  from  the 
hook  in  the  centre  of  the  transverse  bar. 


COXA  VARA 


389 


limbs  can  be  made  simultaneously  by  a  weight  and  pulley  at  the  end  of 
the  bed.  This  transverse  bar  is  designed  to  keep  the  limbs  in  the  requisite 
position  of  abduction  during  extension,  while  its  extremities  provide  fixed 
points  about  which  the  limbs  can  be  rotated  so  as  to  overcome  the  rotation 
outwards.  This  is  done  by  fastening  to  the  hooks  (a)  an  elastic  door 
spring  of  suitable  strength  which  thus  pulls  the  toes  together  while  the 
heels  remain  separated  by  the  transverse  bar  (c).  The  apparatus  must  be 
firmly  fastened  to  the  limb  by  including  it  in  the  folds  of  a  plaster  of 
Paris  bandage  (see  Fig.  134).  The  weight  used  for  extension  should  be 


FIG.  134.  EXTENSION  APPARATUS  FOR  COXA  VARA  APPLIED.  The  iron  bars  are  in- 
corporated in  the  layers  of  a  plaster  of  Paris  bandage  so  that  the  limbs  are  immovably 
fixed  to  them.  Extension  is  made  with  the  limbs  abducted  and  well  rotated  inwards. 
The  extension  is  applied  in  a  somewhat  upward  direction  to  avoid  the  friction  caused  by 
the  heavy  splint  lying  flat  on  the  bed. 

three  or  four  pounds  to  commence  with,  according  to  the  size  of  the 
child  ;   it  may  be  increased  later. 

The  apparatus  should  be  renewed  about  once  a  fortnight,  as  it  is 
liable  to  become  soiled  with  urine.  When  this  is  done,  the  limb  should 
be  massaged,  and  it  is  well  to  practise  repeated  inversion,  flexion,  and 
adduction,  before  the  splint  is  re-applied. 

The  results  obtained  by  this  method  are  often  surprisingly  good  and 
very  rapid.  It  would  therefore  appear  that  at  any  rate  some  part  of  the 
deformity  and  incapacity  from  which  the  child  suffers  must  be  due  to 
muscular  action,  for  it  is  obvious  that  extension  and  traction  could  not 
produce  any  profound  change  in  the  curvatures  of  the  neck  in  so  short  a 
time.  The  extreme  outward  rotation  may  disappear  in  three  weeks, 
although  of  course  the  elevation  of  the  trochanter  still  remains,  and  will 


39° 


DEFORMITIES 


only  be  rectified  very  gradually  as  growth  proceeds  and  the  rickety 
condition  disappears. 

The  elastic  traction  should  be  kept  up  until  all  tendency  to  repro- 
duction of  the  deformity  as  the  child  lies  in  bed  has  disappeared.  This 
will  probably  be  in  from  four  to  six  weeks  in  early  cases.  The  subse- 
quent treatment  should  be  that  appropriate  for  rickets  (see  p.  363),  and 
special  care  must  be  taken  to  prevent  the  limbs  habitually  assuming 
their  old  faulty  position. 

A  simpler  form  of  apparatus  is  shown  in  Fig.  135.  Two  splints,  each 
two  and  a  half  inches  wide,  and  long  enough  to  reach  from  the  axilla  to 
just  beyond  the  heel  are  prepared.  Opposite  to  the  trochanter,  a  piece 
of  wood  the  same  width  as  the  long  splint  and  about  six  inches  long  is 
fixed  to  each  splint  at  right  angles,  the  free  ends  being  perforated  by  a 
half-inch  hole.  Opposite  the  trochanters,  just  above  the  point  where 
the  shorter  pieces  are  attached,  the  two  splints  are  joined  together  by 
a  broad  strip  of  webbing  which  serves  to  keep  them  from  coming 


FIG.  135. — SPLINT  FOR  USE  IN  COXA  VARA.      For  the  sake   of    clearness    the 
bandages  are  omitted. 

forward,  but  is  sufficiently  loose  to  allow  rotation  inward  of  the  whole 
apparatus.  The  splints  are  fixed  firmly  to  the  legs  by  a  spiral  band 
of  strapping  and  bandages  ;  to  the  trunk  they  are  fastened  merely  by 
a  loose  binder.  A  piece  of  elastic  or  string  is  threaded  through  the 
holes  at  the  ends  of  the  short  vertical  pieces,  and  the  whole  leg  is 
rotated  inward  by  tightening  this.  An  improvement  of  fifteen  to 
twenty  degrees  can  be  obtained  in  a  fortnight. 

Operative. — Should  no  improvement  result  after  a  careful  and  pro- 
longed trial  of  this  method,  some  form  of  operative  procedure  designed 
to  overcome  the  excessive  outward  rotation  will  have  to  be  considered. 
Operative  treatment,  however,  is  rarely  called  for  in  young  children,  as 
the  methods  advocated  above  will  certainly  suffice  for  all  but  very 
neglected  cases,  and  there  will  be  fewer  of  these  now  that  the  nature 
of  the  affection  is  widely  recognised.  It  may  be  necessary,  however, 
in  young  adults. 

Sub-trochanteric  Division  of  the  Femur. — In  a  bad  case  in  a  child  we 
obtained  a  good  result  by  dividing  the  femur  below  the  trochanters 
through  a  vertical  incision  four  inches  long  carried  down  to  the  bone 
from  just  below  the  upper  border  of  the  great  trochanter.  The  bone 
was  cleared  with  a  rugine  and  divided  transversely  just  below  the 


COXA  VARA 


lesser  trochanter  with  a  fine-bladed  saw.  The  great  trochanter  was  then 
pushed  as  far  forwards  as  it  would  go,  while  the  leg  and  the  lower  part  of 
the  femur  were  rotated  inwards  until  the  limb  was  in  a  position  of  com- 
plete internal  rotation.  The  two  portions  of  the  bone  were  then  sur- 
rounded by  a  collar  of  sheet  aluminium  fastened  on  by  tacks  and  the 
wound  was  closed  without  a  drainage  tube.  The  limb  was  put  in  a 
trough  of  Gooch's  splinting  which  was  then  raised  on  an  inclined  plane 
and  rotated  inwards  so  as  to  maintain  the  leg  in  a  position  of  internal 
rotation.  The  recently  introduced 
plates  and  screws  which  are  de- 
scribed in  connection  with  the 
mechanical  fixation  of  fractures 
(see  Vol.  II.)  would  probably  be 
preferred  for  the  purposes  of  fixa- 
tion nowadays  (see  Fig.  136) .  The 
after-treatment  is  the  same  as  for 
those  cases. 

The  rationale  of  this  proceed- 
ing is  that  the  hip  joint  is  left 
undisturbed,  whilst  the  rotation 
of  the  foot,  as  far  as  walking  is 
concerned,  is  completely  cor- 
rected, for  although  the  tro- 
chanter does  not  rotate  as  far 
forwards  as  it  should,  the  foot 
is  in  its  normal  position  when 
the  femur  is  rotated  inwards  as 
far  as  it  can  go.  On  the  other 
hand,  when  the  trochanter  is 
rotated  outwards  to  its  extreme 
limit,  the  foot  is  usually  in  the  posi- 
tion of  normal  external  rotation. 

In  young  adults  the  best  treatment  is  by  Thomas's  hip-splint 
applied  as  recommended  for  hip  disease  (see  Vol.  III.).  The  splint  re- 
quires to  be  kept  on  until  all  tenderness  and  pain  have  disappeared.  The 
patient's  general  condition  should  receive  careful  attention,  and  hygienic 
measures  must  be  insisted  on  as  for  tuberculosis  Oleum  phosphoratum 
in  minim  doses,  combined  with  emulsion  of  cod  liver  oil,  is  valuable. 

When  the  bones  have  consolidated,  an  operation  must  be  undertaken  if 
the  degree  of  deformity  be  such  that  the  patient  is  unable  to  walk  unaided. 
In  a  case  which  has  resisted  palliative  treatment  and  in  which  ossification 
is  complete  a  sub-trochanteric  osteotomy  (vide  supra)  will  suffice.  This  is 
preferable  to  excision  of  a  wedge  from  the  neck  of  the  femur  as  proposed 
by  Kraske,  which  is  extremely  difficult  to  perform  ;  it  is  still  more 
difficult  to  fix  the  fragments  afterwards,  and  get  a  good  movable  joint. 


FlG.      136. — SUB-TROCHANTKRIC      OSTEOTOMY      FOR 

COXA  VARA.     In  A ,  the  bones  are  united  by  a  bone- 
plate  ;  in  B,  by  an  aluminium  collar. 


392 


DEFORMITIES 


COXA  VALGA. 


In  this  deformity  the  head  of  the  femur  is  displaced  upwards,  and 
the  shaft  is  abducted ;  in  other  words  there  is  an  increase  in  the  angle 
made  by  the  neck  of  the  femur  with  the  shaft.  Associated  with  this 
alteration  in  the  angle  there  may  be  a  curvature  backwards  or  forwards 
of  the  neck.  The  deformity  is  present  to  some  extent  in  the  majority 
of  cases  of  congenital  dislocation  of  the  hip  ;  it  is  then  probably  secondary 
to  dislocation  forwards  of  the  head  of  the  bone.  It  has  also  been  described 
in  association  with  infantile  palsy,  as  a  result  of  rickets,  secondary  to 
genu  valgum,  and  as  a  sequel  of  some  forms  of  fracture  of  the  neck  of  the 
femur.  The  signs  are  abduction  and  external  rotation  of  the  limb,  with 
limitation  of  adduction  and  inversion.  In  unilateral  cases,  there  is  an 
increased  length  of  the  limb.  There  is  flattening  over  the  great  trochanter, 
which  may  be  below  the  level  of  Nekton's  line.  The  outer  aspect  of  the 
trochanter  may  also  be  directed  backwards.  Very  little  is  really  known 
either  of  the  pathology  or  the  treatment  of  this  affection;  we  shall 
therefore  not  go  further  into  the  matter  at  present. 


CHAPTER    XX. 
CONGENITAL  DISLOCATION  OF  THE  HIP. 

THE  hip  joint  is  not  infrequently  the  subject  of  congenital  dislocation, 
and  the  affection  is  much  more  commonly  met  with  in  females  than  in 
males.  The  deformity  may  be  unilateral  or  bilateral ;  probably  it  is 
more  often  bilateral. 

PATHOLOGY. — The  condition  commonly  met  with  in  children 
under  the  age  of  puberty  is  displacement  of  the  head  of  the  femur 
upwards  from  the  acetabulum  so  that  it  lies  just  beneath  the  anterior 
superior  spine  of  the  ilium.  As  the  child  gets  older  and  heavier  and 
walks  more,  the  head  passes  backwards,  until  eventually  there  is  a  typical 
dislocation  on  the  dorsum  ilii.  In  the  early  cases  there  may  be  very 
little  lordosis  as  long  as  the  head  of  the  bone  lies  immediately  above  the 
acetabulum  ;  as  the  head  passes  on  to  the  dorsum  the  lordosis  becomes 
well  marked.  The  head  of  the  bone  is  practically  unaltered  in  early 
cases,  but  in  long-standing  cases  (after  seven  years)  it  may  be  flattened 
and  mushroom-like.  The  acetabulum  is  always  present  but  is  smaller 
than  normal,  and  is  often  almost  entirely  masked  by  the  anterior  part 
of  the  capsule  of  the  joint  which  is  tightly  stretched  across  it  and 
bound  down  by  the  tendon  of  the  psoas,  so  that  only  a  small  slit-like 
aperture  is  left  leading  into  the  acetabular  cavity.  The  neck  of  the 
bone  is  invariably  rotated  forwards,  and  this  is  an  important  point  to 
bear  in  mind  during  treatment.  The  ligamentum  teres  is  represented 
by  a  thin  elongated  cord,  or  is  entirely  absent. 

When  the  dislocation  has  lasted  for  more  than  a  few  months,  contrac- 
tion occurs  in  the  muscles  surrounding  the  joint  and  not  only  prevents 
the  head  of  the  femur  from  being  brought  into  position  but  also  interferes 
with  walking.  The  muscles  most  affected  are  the  adductors  which 
draw  the  affected  limb  inwards ;  in  extreme  bilateral  cases  a  condition 
of  cross-legged  deformity  may  be  produced.  There  is  always  some 
lordosis  which  increases  as  the  child  grows  older  and  is  most  apparent 
on  standing.  In  unilateral  cases  there  is  generally  some  scoliosis  also. 

393 


394  DEFORMITIES 

In  the  early  stages  it  is  generally  possible,  at  any  rate  during  the 
first  two  or  three  years  of  life,  to  bring  the  head  of  the  bone  nearly,  if 
not  quite,  down  to  its  normal  level  by  steady  extension,  and  while  doing 
this  it  is  often  possible  to  feel  a  definite  click  as  the  head  comes  down 
over  the  edge  of  the  acetabulum.  If  the  pelvis  be  fixed  with  one  hand 
and  the  affected  limb  grasped  with  the  other,  the  head  of  the  femur  can 
be  moved  up  and  down  in  a  vertical  direction  over  the  side  of  the  pelvis 
in  young  children.  In  later  life,  when  the  upward  dislocation  has  become 
converted  into  a  dorsal  one,  this  vertical  movement  is  not  so  free.  The 
gait  is  marked  by  a  peculiar  waddling  movement  which  is  due  to  the 
sliding  of  the  head  of  the  femur  over  the  surface  of  the  innominate  bone, 
and  in  addition  there  is  lordosis  and  adduction  of  the  affected  thigh. 
The  condition  is  of  considerable  gravity  on  account  of  the  increasing 
difficulty  in  walking  as  age  advances. 

TREATMENT. — It  is  important  to  discriminate  between  the  cases 
in  which  good  results  may  be  expected  from  treatment  and  those  in  which 
nothing  can  be  done.  There  are  some  in  which  the  lordosis  is  so  slight 
and  the  waddling  gait  so  little  marked  that  it  is  inadvisable  to  undertake 
any  treatment,  especially  if  the  deformity  be  bilateral.  Similarly,  treat- 
ment does  not  do  much  good  when  the  displacement  is  considerable  and 
the  contraction  of  the  soft  parts  is  so  great  that  there  is  little  chance  of 
getting  the  head  of  the  bone  down  to  the  acetabulum.  Those  cases  are 
best  suited  for  treatment  in  which  the  deformity  is  unilateral,  and  there 
is  such  free  mobility  of  the  head  that  it  is  apparently  not  difficult  to  get 
it  down  to  the  acetabulum.  Surgical  measures  should  always  be  adopted 
in  cases  of  dorsal  displacement ;  there  is  then  at  least  the  certainty  of 
converting  the  dorsal  displacement  into  an  anterior  one,  and  this  may 
be  made  stable  in  many  cases  by  a  prolonged  use  of  the  plaster  of  Paris 
bandage  recommended  below. 

There  are  two  methods  of  treatment  which  give  fairly  good  results, 
and  for  which  we  are  indebted  to  the  work  of  foreign  surgeons,  chiefly 
Lorenz,  Hoffa,  and  Paci.  The  object  is  to  replace  the  head  of  the  bone 
in  the  rudimentary  acetabulum  either  with  or  without  an  open  operation 
first  of  all,  and  then  gradually  to  form  an  efficient  hip- joint.  Although 
both  these  methods  show  a  distinct  improvement  upon  the  older  ones, 
they  nevertheless  frequently  fail  to  give  a  perfect  result.  They  are 
chiefly  applicable  to  children  between  the  ages  of  two  and  seven  years  ; 
before  and  after  that  time  little  can  be  done  beyond  the  employment 
of  apparatus.  It  may  be  possible  to  obtain  a  good  result  by  operative 
means  in  children  over  seven  years  of  age,  but  it  is  rare. 

We  shall  describe  first  the  treatment  for  cases  in  early  infancy  before 
the  child  has  learned  to  walk.  After  this  will  come  the  non-operative 
method  which  is  now  carried  out  chiefly  by  Lorenz's  method  and  which 
is  most  suitable  for  children  who  are  three  or  four  years  old  and  have 
learnt  to  walk.  Finally  we  shall  describe  the  method  by  open  operation 


CONGENITAL  DISLOCATION  OF  THE  HIP  395 

which  may  either  be  employed  when  the  non-operative  one  has  failed  or 
when  the  child  is  too  old  for  it  to  be  likely  to  succeed. 

In  Infancy. — The  existence  of  the  deformity  is  often  recognised 
in  infancy  ;  the  nurse  calls  the  doctor's  attention  to  something  wrong  in 
the  hip-joint  and  the  existence  of  a  congenital  dislocation  is  recognised. 
A  radiogram  will  show  at  once  whether  there  be  a  dislocation  present  or 
not.  The  clear  space  corresponding  to  the  Y-cartilage  in  the  acetabulum 
is  always  seen,  and  this  should  be  opposite  to  the  equator  of  the  head  of 
the  femur.  If  there  be  a  dislocation  the  head  is  above  this  line.  The 
question  then  arises  as  to  what  steps  are  to  be  taken  at  this  early  age, 
since  an  essential  point  in  the  methods  described  below  is  that  the  patient 
shall  be  able  to  walk,  and  therefore  it  is  seldom  advisable,  or  indeed 
possible,  to  practise  them  until  the  child  is  two  and  a  half  or  three  years 
old.  Some  treatment,  however,  should  be  undertaken  as  soon  as  the 
nature  of  the  case  is  recognised.  Massage  and  manipulations  should  be 
practised  during  the  time  that  must  elapse  before  the  child  is  of  a  fit 
age  for  the  treatment  recommended  below.  In  early  infancy  there  is 
no  difficulty  in  bringing  the  head  of  the  bone  down  to  its  proper  level 
and  this  should  be  done  several  times  daily  by  the  nurse,  and  will  serve 
to  prevent  shortening  of  the  muscles.  When  the  head  of  the  bone  has 
been  pushed  well  down,  gentle  outward  rotation,  with  abduction  and  hyper- 
extension  of  the  limb,  may  be  carried  out.  If  this  treatment  be  persisted 
in,  it  should  facilitate  the  subsequent  reduction  of  the  deformity.  Some 
surgeons  prefer  to  put  the  child  up  in  an  extension  apparatus,  but  this 
is  not  so  satisfactory  as  the  method  we  have  described,  because  it  is 
impossible  to  fix  an  infant  up  properly,  and  moreover  extension  does  not 
stretch  the  muscles  in  the  various  directions  that  are  necessary. 

Lorenz's  Non-Operative  Method. — The  object  of  this  procedure  is  to 
bring  the  head  of  the  fgmur  down  into  position  over  the  rudimentary 
acetabulum,  to  keep  it  there,  and  then  to  cause  it  to  enlarge  and  deepen 
the  rudimentary  cavity  by  pressure  and  friction  as  the  child  walks,  until 
a  more  normal  acetabulum  is  formed.  The  first  essential  for  success  is 
that  the  patient  should  be  young ;  at  the  same  time  it  is  of  primary 
importance  that  the  child  should  have  learnt  to  walk  and  also  that  it 
should  be  sufficiently  cleanly  in  its  habits  to  avoid  soiling  the  bandages. 
After  the  child  has  reached  the  age  of  seven  years,  the  chance  of  bringing 
the  head  of  the  femur  successfully  down  over  the  acetabulum  without  an 
open  operation  is  very  slight,  because  of  the  shortening  of  the  muscles, 
ligaments,  and  soft  tissues  generally,  and  therefore,  if  non-operative 
treatment  is  to  succeed,  it  should  be  employed  before  this  age.  In  young 
children  it  is  often  easy  to  get  the  head  of  the  bone  into  position  over 
the  acetabulum  without  an  open  operation,  but  attempts  to  push  it  into 
the  small  slit  that  leads  into  the  acetabulum  generally  fail,  partly  because 
of  the  tension  on  the  front  part  of  the  capsule,  and  partly  because  the 
head  of  the  femur  is  too  large  to  pass  through  the  slit.  If,  however,  the 


396 


DEFORMITIES 


anterior  part  of  the  capsule  be  stretched  or  divided,  the  head  of  the  bone 
will  go  into  the  rudimentary  acetabulum  and  then  the  limb  can  be  im- 
mobilised in  that  position.  The  following  are  the  stages  of  the  procedure 
as  practised  by  Lorenz. 

First  of  all  the  head  must  be  brought  down  to  the  level  of  the  aceta- 
bulum, next  the  adductors  must  be  so  stretched  that  they  are  incapable  of 
reproducing  the  deformity,  then  the  capsule  must  be  detached  from  the 
front  of  the  acetabulum  and  finally  the  head  of  the  bone  must  be  brought 


FIG.  137. — LORENZ'S  NON-OPERATIVE  METHOD  FOR  CONGENITAL  DISLOCATION  OF 
THE  HIP.  First  Stage.  While  an  assistant  makes  counter-extension  by  a  perineal  band, 
the  surgeon  forcibly  pulls  down  the  head  of  the  bone  until  it  is  opposite  the  acetabulum. 
The  traction  is  made  outwards  as  well  as  downwards,  so  as  to  stretch  the  adductors. 

over  the  rudimentary  acetabulum,  where  it  is  kept  until  the  head  has 
enlarged  it  sufficiently  to  establish  a  stable  joint  on  which  the  patient  may 
walk  without  the  dislocation  recurring.  We  shall  describe  the  treatment 
of  a  case  of  unilateral  dislocation ;  although  the  steps  of  the  treatment 
are  similar  for  both  unilateral  and  bilateral  forms,  the  former  condition 
is  much  more  easy  to  treat  because  the  patient  possesses  one  sound  limb 
on  which  to  support  himself  when  walking  becomes  necessary. 

The  child  is  anaesthetised,  and  forcible  extension  is  made  upon  the 
thigh  so  as  to  bring  the  trochanter  down  to  the  level  of  Nelaton's  line,  while 
counter-extension  is  exerted  by  a  well-padded  perineal  band.  The  more 
important  part  of  the  procedure  consists  in  over-stretching  or  actually 
rupturing  the  shortened  adductors,  and  thereby  paralysing  them  and 


CONGENITAL  DISLOCATION  OF  THE  HIP  397 

rendering  them  unable  to  reproduce  the  deformity.  In  order  to  do 
this  effectually,  the  pelvis  is  steadied  by  an  assistant  who  presses  upon 
the  anterior  superior  iliac  spine  on  the  sound  side  while  the  surgeon 
attempts  to  abduct  the  affected  limb  to  a  full  right  angle.  The  adductors 
resist  this,  and  their  resistance  is  overcome  by  striking  the  tense  muscles 
repeatedly  with  the  ulnar  border  of  the  hand  while  the  extremest  abduc- 
tion possible  is  maintained.  The  stretched  and  contused  adductors  at  last 
give  way  and  allow  full  abduction  of  the  limb  to  be  obtained  ;  considerable 
subcutaneous  effusion  of  blood  usually  follows  this.  Finally  all  the 
muscles  around  the  joint  are  stretched  by  exaggerating  the  movements 
of  the  limb  in  all  directions,  especially  in  that  of  over-extension. 


FIG.  138.  LORENZ'S  NON-OPERATIVE  METHOD  FOR  CONGENITAL  DISLOCATION  OF 
THE  HIP.  Second  Stage.  The  limb  is  rotated  outwards  and  abducted  to  its  fullest 
degree  after  the  head  has  been  brought  down  over  the  acetabulum.  The  adductors 
require  much  kneading  by  the  surgeon's  fingers,  as  is  shown  in  the  drawing.  The  hip 
joint  is  also  fully  extended. 

After  satisfactory  stretching  of  the  muscles  has  been  obtained,  the 
next  step  is  to  try  to  detach  the  capsule  from  the  front  of  the  joint.  This 
is  done  by  the  ordinary  manipulations  for  dislocation  of  the  hip  fre- 
quently repeated;  at  first  complete  flexion  of  the  limb  with  rotation 
inwards,  followed  by  abduction,  rotation  outwards,  and  extension.  It  is 
the  latter  manipulations  which  aim  at  getting  the  soft  material  peeled  off 
the  surface  of  the  acetabulum. 

The  head  of  the  bone  is  got  into  the  acetabulum  by  the  following 
manipulations.  An  assistant  steadies  the  pelvis,  and  the  surgeon,  flexing 
the  hip  joint  to  a  right  angle,  makes  traction  upon  the  thigh  in  its  long 
axis,  while  at  the  same  time  he  presses  the  great  trochanter  inwards 
against  the  pelvis.  When  the  limit  of  extension  has  been  reached,  the 
limb  is  carried  outwards  through  nearly  90°,  so  that  the  femur  lies  nearly 
flat  upon  the  table  and  at  right  angles  to  the  median  plane  of  the  body. 
By  this  manoeuvre  the  head  of  the  femur  is  made  to  pass  over  the  dorsal 


398  DEFORMITIES 

lip  of  the  acetabulum  —  an  event  usually  marked  by  an  appreciable  click 
—  and  rests  over  or  actually  in  the  acetabular  cavity  into  which  it  is 
firmly  jammed  by  carrying  the  limb  outwards  through  a  right  angle. 
Owing  to  the  fact  that  the  head  and  neck  of  the  bone  are  usually  deflected 
somewhat  forwards,  it  will  be  necessary  to  rotate  the  limb  a  little  inwards, 
in  order  to  get  the  position  of  maximum  stability  ;  the  limb  will  therefore 
be  parallel  to  the  horizontal  plane  of  the  body  but  at  right  angles  to  the 
median  vertical  one,  and  in  addition  it  will  be  slightly  rotated  inwards. 

After-Treatment  —  In  this  position  of  maximum  stability  the  limb  is 
put  up  in  a  plaster  of  Paris  spica,  which,  according  to  Lorenz,  does  not  take 
in  the  knee.  In  this  the  child  is  kept  for  four  or  five  months,  and  is 
allowed  to  crawl  about  as  best  he  may  ;  at  the  end  of  this  time,  another 
spica  is  applied,  after  the  limb  has  been  brought  down  to  a  position  of 

slight  abduction  and  a  little 
flexion.  It  is  somewhat  difficult 
to  apply  the  spica  while  keeping 
the  head  of  the  bone  firmly  in 
place  on  an  ordinary  operating 
table.  Lorenz  has  introduced  a 
special  sacral  rest  upon  which 
the  pelvis  is  supported,  and  this 
is  excellent  for  the  purpose  and 
greatly  simplifies  the  proceedings. 

FIG.  139.  —  LORENZ'S  NON-OPERATIVE  METHOD  FOR  T      ,,  .  ,          ,  ..,    . 

CONGENITAL  DISLOCATION  OF  THE  Hip.     Third  Stage.  J-I1  tillS    apparatus    the  Child   IS 


The  limit  of  stability  of  the  joint  having  been  found  in  pnrrmracrprl  tn  \w\\r  is. 
the  last  stage,  the  lower  extremity  is  put  up  in  the  eUCOUrageQ  tO  WalK  as 
above  position,  the  knee  being  flexed.  possible,  in  Order  to  preSS  the 

head  of  the  femur  against  the 

acetabulum  and  so  deepen  it.  The  treatment  lasts  for  eight  to 
ten  months. 

We  are  accustomed  to  depart  slightly  from  this  procedure.  In  the 
first  place  the  serious  troubles  following  the  rough  handling  of  the  muscles, 
such  as  haematoma,  abscess,  cellulitis,  etc.,  lead  us  to  prefer  subcutaneous 
division  of  the  adductors  close  to  their  origin  from  the  pelvis.  This  we 
do  about  a  week  before  the  reduction,  and  the  manipulations  are  rendered 
easier  thereby,  and  at  the  same  time  less  likely  to  be  followed  by  com- 
plications. In  the  second  place  we  invariably  include  the  knee  in  the 
first  plaster.  It  seems  to  us  that,  until  the  parts  are  sufficiently  adapted 
to  their  new  position  to  keep  the  head  of  the  bone  in  place  unaided,  it  is 
essential  to  avoid  rotation  of  the  femur  under  the  plaster,  which  can  occur 
with  the  greatest  ease  unless  the  knee  be  included. 

The  child  is  not  allowed  to  come  round  from  the  anaesthetic  until  the 
plaster  casing  has  set  ;  it  is  well  to  strengthen  the  latter  with  strands  of 
tow  impregnated  with  plaster  cream  opposite  the  points  of  greatest  strain. 
At  first  the  child  complains  a  good  deal,  but  the  pain  usually  disappears 
in  two  or  three  days.  It  is  well  to  have  a  radiogram  taken  at  this  stage 


CONGENITAL  DISLOCATION  OF  THE  HIP  399 

through  the  plaster  casing,  so  as  to  ascertain  whether  the  head  of  the 
bone  remains  in  place.  Should  it  have  slipped  out  of  position,  the 
displacement  must  be  rectified  and  the  limb  put  up  as  before.  '  The 
plaster  case  is  removed  in  ten  or  twelve  weeks:  should  it  become  sodden 
with  urine  or  faeces,  as  not  infrequently  happens  in  young  female 
children,  the  apparatus  must  be  re-applied,  but  no  change  in  the  position 
of  the  limb  should  be  made  until  after  the  lapse  of  that  time.  If  there  be 
any  doubt  as  to  the  recurrence  of  the  deformity,  a  radiogram  will  settle  the 
question.  During  the  time  that  the  limb  is  in  the  first  plaster  casing  the 
parts  are  becoming  consolidated  after  the  manipulations  to  which  they 
have  been  subjected,  and  the  tissues  around  the  joint  contract,  so  that 
when  the  casing  is  removed,  the  limb  often  retains  its  abducted  position 
spontaneously.  The  abduction  is  now  gradually  diminished  as  long  as 
the  head  of  the  bone  does  not  slip  out  of  position.  Directly  a  position 
reached  in  which  the  head  of  the  bone  is  becoming  unstable,  the  limb 
is  abducted  a  little  more  and  a  little  flexed,  and  the  plaster  of  Paris  spica 
is  re-applied.  The  main  difference  between  the  new  position  and  the  old 
one  is  that  the  degree  of  abduction  is  now  less. 

The  patient  is  now  taught  to  walk  with  the  limb  abducted.  Every 
time  the  weight  is  borne  upon  the  affected  limb,  the  head  of  the  bone 
is  pressed  against  the  acetabulum,  and  the  more  the  child  stands  upon 
the  leg  the  longer  is  this  pressure  maintained,  and  the  more  quickly  is  the 
acetabulum  increased  in  depth.  The  plaster  should  not  be  continued 
below  the  knee  at  the  second  sitting  as  the  leg  is  thus  left  free  for  move- 
ment, which  both  helps  to  maintain  its  nutrition,  and  also  facilitates 
walking ;  the  child  soon  learns  to  walk  without  assistance.  A  radio- 
gram will  show  whether  the  dislocation  has  recurred,  and,  if  it  has,  the 
apparatus  should  be  taken  off  and  the  head  of  the  bone  got  into 
position  again. 

A  very  easy  and  expeditious  way  of  removing  plaster  of  Paris  casings 
is  by  means  of  Gigli's  wire  saw.  Before  the  casing  is  applied,  a  piece  of 
string  dipped  in  oil  or  melted  beeswax  (to  prevent  adhesion  to  the  plaster 
and  subsequent  fraying)  is  laid  along  the  limb  between  the  boric  lint  and 
the  plaster  bandage  and  left  there.  When  the  plaster  is  to  be  removed, 
one  end  of  the  wire  saw  is  attached  to  one  end  of  the  string,  the  other  end 
of  the  latter  is  pulled  upon,  and  the  string  is  withdrawn,  leaving  the  saw 
in  place  beneath  the  plaster.  The  handles  are  then  hooked  on  to  the 
saw,  and  the  casing  can  be  cut  through  in  a  few  seconds.  If  the  casing  be 
a  very  stout  one,  two  pieces  of  string,  one  along  each  side  of  the  limb,  may 
be  used  instead  of  one  along  the  centre. 

After  about  eight  to  ten  months  no  further  apparatus  is  necessary,  the 
soft  parts  having  become  sufficiently  shortened  through  their  prolonged 
rest  in  the  abducted  position  to  keep  the  head  of  the  bone  in  place. 
Indeed,  it  is  common  to  find  that  attempts  to  adduct  the  limb  fully  cause 
pain,  and  the  patient  naturally  keeps  the  limb  somewhat  abducted.  The 


400  DEFORMITIES 

head  of  the  bone  will  usually  keep  in  position  without  the  assistance  of 
any  apparatus. 

Treatment  must  now  be  directed  to  strengthening  the  muscles  about 
the  hip  joint,  especially  the  abductors,  by  massage  and  by  the  use  of 
suitable  exercises  against  resistance.  The  patient  should  attempt  to 
abduct  the  limb,  whilst  the  nurse  opposes  the  movement ;  this  strengthens 
the  abductors,  which  are  the  main  factors  in  keeping  the  parts  in  position. 
Adduction  can  be  guarded  against  by  raising  the  heel  of  the  boot  on  the 
sound  side  about  one  inch  ;  in  time  this  may  be  reduced,  and  ultimately  it 
may  be  done  away  with. 

In  bilateral  dislocation  the  outlook  is  not  favourable,  but  treatment  is 
carried  out  simultaneously  and  in  a  similar  manner  in  the  two  legs.  At 
the  end  of  about  twelve  weeks  abduction  may  be  so  far  reduced  that  the 
patient  can  use  both  legs  in  walking. 

Operative  Methods. — When  a  child  has  reached  the  age  of  seven 
before  it  comes  under  observation,  the  manipulative  methods  almost 
uniformly  fail,  and  the  only  chance  of  benefit  lies  in  the  performance  of  an 
open  operation  ;  experience  has  shown  us  that,  provided  the  articular 
cartilage  be  not  removed,  considerable  improvement  is  often  obtained, 
and,  even  when  the  surgeon  fails  to  get  the  head  of  the  bone  into  the 
acetabulum,  considerable  benefit  will  be  obtained,  since  the  flexion  and 
adduction  of  the  limb  can  be  overcome,  and  fixation  of  the  head  of  the 
bone  can  be  effected. 

The  operation  we  practise  is  done  as  follows.i  The  patient  is  put 
under  an  anaesthetic,  and  any  unduly  tense  structures  are  divided  sub- 
cutaneously ;  those  generally  requiring  division  are  the  adductors  close 
to  their  origin,  the  fascia  lata  of  the  thigh,  and  sometimes  the  muscles 
attached  to  the  anterior  superior  iliac  spine,  and  even  in  bad  cases  the 
hamstrings.  A  week  or  ten  days  later,  under  full  anaesthesia,  manipula- 
tions designed  to  stretch  the  parts  are  first  practised,  and  then  an  incision 
is  made  downwards  and  slightly  inwards  from  just  beneath  the  anterior 
superior  iliac  spine,  over  the  interval  between  the  sartorius  and  the  tensor 
fasciae  femoris  ;  in  order  to  facilitate  access  to  the  deeper  structures  the 
upper  end  of  this  incision  may  be  curved  out  along  the  iliac  crest,  and 
the  tensor  fasciae  femoris  detached  from  the  bone  (see  Fig.  140).  This 
incision  divides  nothing  of  importance,  and  gives  satisfactory  access  to 
the  joint.  The  head  and  neck  of  the  bone  are  exposed,  and  the 
capsule  of  the  hip  joint  is  slit  up  from  the  anterior  inter- trochant eric 
line  to  the  rim  of  the  acetabulum.  The  finger  is  passed  into  the  joint 
and  feels  for  the  slit  leading  into  the  true  acetabular  cavity.  If  this  be 
too  small  to  admit  the  head  of  the  bone,  the  front  portion  of  the 
capsule  is  detached  from  the  rim  of  the  acetabulum  sufficiently  to  allow 
the  head  to  pass  through  it  into  position. 

1  See  Brit.  Med.  Journ.,  1903,  ii.  p.  457. 


CONGENITAL  DISLOCATION  OF  THE  HIP  401 

An  attempt  is  next  made  to  get  the  head  of  the  bone  into  position  by 
smtable  manipulations  ;  these  will  be  generally  similar  to  those  practised 
in  the  non-operative  method.  The  surgeon  has  the  advantage  in  the  open 
method,  however,  that  he  is  able  to  see  when  the  head  of  the  bone  goes  into 
place,  which  it  usuaUy  does  with  a  definite  snap,  just  as  it  does  in  trau- 
matic dislocations  that  are  reduced.  When  the  head  has  been  got  into 
place,  the  position  of  maximum  stability  is  found,  and  the  limb  is  kept  in 
that  position  until  the  wound  has  been  closed  and  a  plaster  of  Paris  spica 
has  been  applied.  This  position  is  generally  similar  to  that  in  the  non- 
operative  method,  viz.,  full  abduction,  slight  extension,  and  inward 
rotation,  but  it  varies  very  much  in  individual  cases  and  depends  to  a 
large  extent  upon  the  deflection  forwards  of  the  neck  that  has  taken 
place.  There  is  never  any  doubt  as  to  the  right  position,  however,  as  it  is 
the  only  one  in  which  the  head 
remains  in  the  acetabulum. 

Before  closing  the  wound  an 
attempt  should  be  made  to 
narrow  the  dilated  front  part 
of  the  capsule  of  the  hip-joint 
sufficiently  to  allow  it  to  exert 
some  influence  in  preventing 
recurrence  of  the  dislocation. 
We  usually  excise  a  large  ellip- 
tical piece  from  it  and  bring  the 
edges  together  with  stout  cat- 
gut. The  deeper  structures  are 

then  brought  together  with  catgut,  and  the  wound  is  closed  without 
drainage.  The  limb  is  put  up  in  a  plaster  of  Paris  spica  in  the 
position  mentioned  above,  and  it  should  be  kept  in  this  for  about  ten 
days,  at  the  end  of  which  time  the  stitches  are  taken  out,  and  a 
second  plaster  casing  is  applied.  If  a  Gigli's  wire  saw  be  used,  there  is 
no  difficulty  in  removing  the  plaster  casing  without  risk  of  disturbing 
the  position  of  the  joint  surfaces.  The  case  is  now  treated  on  lines 
exactly  similar  to  those  for  the  bloodless  method  (see  p.  398). 

Results. — The  results  of  this  operation  are  often  very  satisfactory,  and 
we  have  had  a  number  of  cases  in  which  the  head  of  the  bone  has  appar- 
ently remained  in  the  acetabulum,  which  has  developed  normally.  In 
others  the  head  has  slipped  out  of  place  within  a  few  days  or  weeks  of 
the  operation  subsequently,  and  in  some  of  these  we  have  successfully 
re-opened  the  wound  and  replaced  the  head.  Sometimes,  however, 
failure  results  either  from  inability  to  get  the  head  of  the  bone  in  place 
at  the  operation  owing  to  long-standing  and  general  shortening  of  the 
tissues  or  from  inability  to  keep  the  head  in  place  afterwards.  In  these 
cases  the  head  lodges  beneath  the  anterior  superior  iliac  spine,  and  a 
good  firm  new  joint  may  result. 


FIG.  140.— INCISION  FOR  THE  OPERATIVE  TREATMENT 
OF  CONGENITAL  DISLOCATION  OF  THE  HIP.  The  line 
ab  runs  in  the  interval  between  the  sartorius  and 
the  tensor  vaginae  femoris  muscles,  from  which 
there  is  easy  access  to  the  hip-joint.  The  dotted 
line  cd  shows  the  second  incision,  if  more  room  be 
required. 


DD 


402  DEFORMITIES 

We  have  now  had  the  opportunity  of  watching  many  cases  treated  both 
by  the  operative  and  non-operative  methods  for  many  years  after  the 
dislocation  has  been  reduced,  in  some  instances  for  twelve  years  or  more. 
On  the  whole  we  must  confess  that  the  later  results  have  disappointed 
us.  The  tendency  to  recurrence  of  the  displacement  never  seems  to  be 
overcome  entirely,  and  we  have  had  a  case  of  spontaneous  recurrence  of 
the  displacement  ten  years  after  apparently  perfect  re-position  by  the 
open  method.  During  all  this  time  the  child  showed  no  sign  of  limping, 
and  lived  her  usual  life,  and  a  series  of  radiograms  taken  annually  showed 
the  head  of  the  bone  apparently  in  perfect  position  in  a  normally  placed 
and  developed  acetabulum.  It  may  be  that  the  loss  of  the  ligamentum 
teres  has  something  to  do  with  this.  In  no  case  have  we  had  any  anchy- 
losis, nor  indeed  any  troublesome  stiffness  of  the  joint  after  the  casings  are 
removed,  and  this  we  attribute  partly  to  avoidance  of  sepsis,  but  chiefly 
to  abstinence  from  interference  with  the  shape  of  the  articular  surfaces. 
In  the  older  open  operation  of  Hoffa  the  joint  surfaces  were  remodelled, 
and  anchylosis  was  a  frequent  result. 

Summary  of  Treatment. — All  cases  seen  in  infancy  should  be  treated 
by  manipulations  (see  p.  395)  until  the  child  is  two  or  three  years  old, 
and  then  Lorenz's  bloodless  method  (see  p.  395)  should  be  tried.  Should 
this  fail  after  a  second  attempt,  or  should  the  child  be  seven  or  eight  years 
of  age  when  treatment  is  begun,  the  open  operation  should  be  resorted  to. 
No  case  under  the  age  of  eight  years  should  be  abandoned  as  incurable 
until  open  operation  has  been  tried,  and  no  case  should  be  called  a  cure 
unless  a  stereoscopic  radiogram  shows  that  the  head  of  the  bone  lies  in  the 
acetabulum.  Provided  that  the  surgeon  be  sure  of  his  asepsis  there  is  no 
risk  attaching  to  the  operation,  which  is  not  unduly  prolonged  nor 
accompanied  by  severe  bleeding.  The  really  difficult  point  is  to  keep  the 
limb  in  its  proper  position  during  the  suturing  of  the  wound,  etc. 


OTHER  CONGENITAL  DISLOCATIONS. 

Congenital  dislocation  is  sometimes  seen  in  the  shoulder  joint,  the 
head  of  the  humerus  being  usually  displaced  backwards  on  to  the  scapula  ; 
occasionally  a  downward  or  forward  displacement  may  be  present. 

In  the  elbow  joint,  the  head  of  the  radius  is  not  very  uncommonly 
displaced  forwards  on  to  the  lower  end  of  the  humerus.  If  the  move- 
ments of  the  fore-arm  be  interfered  with,  the  head  of  the  bone  may  be 
excised,  but  as  a  rule  no  treatment  is  necessary.  Sometimes  both  ulna 
and  radius  are  displaced  backwards. 

Displacements  of  the  knee-joint  or  of  the  patella  in  a  lateral  direction, 
also  occur  as  a  congenital  deformity.  They  do  not  need  any  special 
description. 


CHAPTER   XXI. 
KYPHOSIS:    SCOLIOSIS. 

UNDER  this  heading  are  included  the  forms  of  spinal  curvature  which 
are  not  due  to  disease  of  the  vertebrae,  in  contradistinction  to  the 
disease  known  as  angular  curvature  or  Pott's  disease,  which  is  due  to 
a  tuberculous  affection. 

Two  forms  of  functional  curvature  of  the  spine  are  met  with  in 
practice.  The  first  is  known  as  kyphosis,  or  general  curvature  of  the 
spine ;  and  although  in  time  it  may  lead  to  the  second  and  more  serious 
form  known  as  scoliosis,  it  is,  as  a  rule,  transient  in  nature  and  easy  to 
treat. 

KYPHOSIS. 

In  Infancy. — This  is  usually  associated  with  considerable  muscular 
weakness,  and  also  with  rickets.  As  a  rule  it  is  temporary,  and  disappears 
as  the  child  grows  stronger.  In  bad  cases,  however,  especially  in  those 
with  extensive  rickets,  the  curvature  persists,  and  the  child  grows  up 
round-backed  and  stooping.  The  condition,  if  persistent,  is  very  likely 
to  become  the  starting-point  of  scoliosis,  and  therefore  always  requires 
treatment. 

A  child  who  is  the  subject  of  kyphosis  has  a  constant  tendency  to  sprawl 
upon  the  back,  and  is  unable  voluntarily  to  assume  the  sitting  posture. 
When  the  child  is  sat  up,  the  trunk  is  bunched  forward  and  the  spine 
is  strongly  bowed  backwards,  so  that  the  chin  often  nearly  touches  the 
knees  and  the  spine  is  bent  forwards  into  one  large  C-hke  curve.  There 
is  no  want  of  mobility  of  the  spine,  and  usually  no  tenderness  on  pressure. 
The  curvature  disappears  entirely  when  the  child  is  laid  flat  on  the  back 
upon  a  hard  level  surface,  except  in  advanced  cases  of  long  standing. 
There  is  no  lateral  curvature  unless  the  kyphosis  has  persisted  for  a 
considerable  time. 

In  Adult  Life. — Kyphosis  in  the  adult  is  generally  due  to  the  habitual 
adoption  of  an  exaggerated  faulty  position,  such  for  instance  as  that 

403  D  D  2 


404  DEFORMITIES 

assumed  by  some  bicyclists.  At  a  more  advanced  age  the  condition  may 
result  from  senile  degeneration  ;  the  spinal  muscles  lose  their  tone,  and 
the  vertebral  column  becomes  bowed  forward  in  consequence.  This 
of  course  is  part  of  general  debility,  and  calls  for  no  special  treatment. 
Kyphosis  may  complicate  general  diseases  such  as  osteo-arthritis  and 
osteo-malacia.  It  is  also  common  in  osteitis  deformans,  and  is  met  with 
in  some  forms  of  paralysis,  in  which  it  is  due  to  atrophy  of  the  erectors  of 
the  spine. 

TREATMENT. — In  infants  it  is  of  the  first  importance  that  the 
child  should  always  be  carried  in  the  horizontal  position,  and  never  be  sat  up 
in  the  nurse's  arms.  The  upright  position  favours  the  bending  forward 
of  the  head,  which,  in  a  weakly  subject,  leads  to  bowing  of  the  spine  and 
this  condition  of  kyphosis.  With  an  intelligent  nurse  it  is  easy  to  have 
this  order  properly  carried  out,  and  no  apparatus  is  necessary.  In  the  case 
of  hospital  patients,  however,  it  is  well  to  insist  that  the  child  shall  be 
carried  about  on  some  form  of  tray,  upon  which  it  lies  always  in  a  hori- 
zontal position.  Wickerwork  trays,  appropriately  padded,  can  be  bought, 
and  are  very  suitable  and  inexpensive.  A  basket-lid  or  an  ironing-board 
padded  with  a  folded  blanket  answers  the  purpose  quite  well. 

When  the  child  approaches  the  end  of  its  first  year,  and  begins  to 
sit  up  and  crawl  about,  it  is  not  so  easy  to  keep  him  in  the  horizontal 
position  as  when  he  is  quite  young ;  for  these  children  the  horizontal 
position  must  be  insisted  upon  as  much  as  possible,  but  in  addition 
it  is  well  to  apply  some  light  spinal  support  which  will  prevent 
bending  of  the  vertebral  column.  We  are  in  the  habit  of  moulding  a 
sheet  of  guttapercha,  leather,  or  poroplastic  felt  over  the  sides  and 
back  of  the  thorax,  and  fixing  it  above  and  below  by  bands  of  webbing 
passing  across  the  front  of  the  shoulders  and  the  upper  parts  of  the 
thighs,  steadying  the  whole  by  a  firm  bandage.  This  provides  a  light 
but  stiff  support  which  counteracts  any  tendency  of  the  spine  to  assume 
the  bent  position,  and  the  child  may  be  allowed  to  sit  up  and  crawl  about 
with  comparative  freedom  wearing  this  apparatus. 

The  general  health  must  receive  careful  attention.  If  rickets  be 
present,  the  measures  appropriate  for  that  affection  (see  Vol.  II.)  must  be 
adopted.  Cod  liver  oil  and  iron  are  of  benefit,  as  is  massage  of  the  back 
muscles  night  and  morning  for  ten  minutes  at  a  time. 

The  kyphosis  of  adult  life  resulting  from  faulty  positions  must  be 
treated  by  attention  to  posture  and,  if  necessary,  giving  up  the  particular 
occupation  that  has  brought  about  the  curvature.  In  addition,  it  is 
well  to  order  massage  and  gymnastic  exercises  designed  to  extend  the 
spine  and  strengthen  the  erector  muscles.  These  are  described  on  p.  423. 
The  treatment  of  the  kyphosis  occurring  in  the  course  of  diseases 
such  as  osteo-arthritis,  osteo-malacia,  and  osteitis  deformans  must  be 
that  of  the  primary  disease  of  which  the  spinal  deformity  is  a  mere 
episode,  which  does  not,  as  a  rule,  gives  rise  to  any  discomfort. 


SCOLIOSIS 


SCOLIOSIS. 


405 


By  scoliosis  is  understood  a  lateral  deviation  of  the  spine,  accom- 
panied by  rotation  of  the  vertebrae  upon  their  vertical  axes ;  this  latter 
occurrence  is  essential  for  the  production  of  true  scoliosis,  for  it  is  possible 
to  have  a  lateral  deviation  of  the  spine  without  rotation  of  the  vertebrae 
— when  the  case  is  strictly  one  of  lateral  curvature  rather  than  of  trae 
scoliosis.  The  two  terms  should  be  kept  distinct,  but  at  the  same  time 
it  must  be  remembered  that  many  cases  of  true  scoliosis  commence  as 
simple  lateral  deviation  of  the  spinal  column,  and  the  rotation  of  the 
vertebras  only  takes  place  at  a  later  period ;  this  is  particularly  the  case 
when  the  spinal  muscles  are  weak.  Simple  lateral  curvature,  if  treated 
sufficiently  early,  does  not  necessarily  give  rise  to  true  scoliosis. 

CAUSES. — We  shall  not  attempt  to  go  at  length  into  the  mechanics 
of  this  condition,  but  various  experiments  seem  to  prove  that  the  most 
essential  factor  in  the  production  of  scoliosis  is  the  transmission  of  the 
weight  of  the  upper  part  of  the  body  through  a  vertebral  column,  which, 
by  the  enfeeblement  of  its  various  muscles,  or  by  the  habitual  mainten- 
ance of  a  faulty  position,  has  undergone  lateral  deviation.  The  constant 
pressure  acting  upon  a  spinal  column  so  deflected  will  inevitably  produce 
rotation  of  the  vertebras  on  account  of  the  conformation  of  the  con- 
stituent parts  of  the  curved  spine  and  their  articulations. 

The  condition  is  predisposed  to  by  any  cause  of  general  debility, 
particularly  rickets  and  anaemia,  and  is  greatly  favoured  by  over-fatigue 
and  the  constant  assumption  of  faulty  attitudes.  The  latter,  by  causing 
a  deviation  of  the  spinal  column,  place  the  spinal  muscles  on  one  side 
at  a  mechanical  disadvantage  compared  with  their  fellows  on  the  opposite 
side,  and,  if  a  faulty  position  be  assumed  habitually,  the  muscles  that  are 
at  a  mechanical  advantage  will  keep  up  or  even  accentuate  the  curvature, 
and  will  eventually  produce  the  rotation  of  the  vertebras  already  spoken  of. 
This  rotation  always  takes  place  in  one  direction  ;  the  bodies  of  the 
vertebras  are  rotated  outwards  towards  the  convexity  of  the  curve, 
whilst  the  spinous  and  other  processes  are  rotated  inwards  towards  the 
concavity — i.e.  towards  the  middle  line  of  the  body. 

It  will  perhaps  help  to  make  the  matter  clear  from  the  point  of  view 
of  treatment  if  we  classify  cases  of  lateral  curvature,  according  to  their 
causes  into  four  main  groups : 

Cases  due  to  inequality  in  length  of  the  supports  of  the  spine.— 
This  group  is  of  the  highest  importance,  and  embraces  many  causes 
which  are  constantly  met  with  in  practice.  Unless  the  base  of  the 
support  of  the  spine  (i.e.  the  sacrum)  be  horizontal,  a  certain  amount 
of  curvature  must  necessarily  result.  However  slight  the  obliquity  may 
be,  it  is  sufficient  to  prove  the  starting-point  of  a  severe  scoliosis  in  sus- 
ceptible subjects.  In  strong  healthy  persons,  on  the  other  hand,  this 


406  DEFORMITIES 

obliquity  may  be  corrected  easily  and  pass  practically  unnoticed.  A  very 
common  cause  is  obliquity  of  the  pelvis,  resulting  from  an  inequality  in 
length  of  the  two  lower  limbs.  This  may  occur  from  various  causes, 
such  as  tuberculous  hip  disease,  congenital  dislocation  of  the  hip,  the 
arrest  of  development  which  follows  infantile  paralysis,  simple  asymmetry, 
etc.  In  weakly  subjects  scoliosis  is  a  common  complication  of  bad  genu 
valgum  or  even  of  flat  foot.  The  primary  curve  in  this  group  is  usually 
in  the  lumbar  or  lower  dorsal  region. 

Cases  due  to  inequality  in  the  weight  borne  on  the  two  sides  of 
the  spine. — Common  examples  of  this  are  seen  in  nursemaids  who 
habitually  carry  children  upon  one  arm,  labourers  carrying  hods,  pails,  or 
heavy  weights  always  on  the  same  side,  or  cases  in  which  amputation  at 
one  shoulder  joint  has  been  performed  in  a  young  subject.  Scoliosis  does 
not  necessarily  occur  in  every  case  in  which  unequal  weights  are  carried 
on  the  two  sides  ;  as  long  as  the  subject  is  strong  and  vigorous,  and  the 
weight  carried  is  not  out  of  proportion  to  the  strength  of  the  muscles,  the 
latter  are  able  to  maintain  their  tone  and  to  keep  the  spine  erect  when 
the  position  of  rest  is  assumed.  When,  however,  the  muscular  system  is 
weak  or  the  weight  is  excessive,  and  particularly  when  it  is  carried  for 
long  periods  at  a  time,  scoliosis  is  apt  to  result. 

Cases  primarily  due  to  weakness  of  the  spinal  muscles,  aided  by  the 
habitual  assumption  of  a  faulty  position. — This  cause  is  responsible 
for  a  large  number  of  cases.  As  long  as  the  patient  is  in  good  health, 
the  muscles  upon  the  two  sides  of  the  spine  act  together  to  keep  that 
structure  erect ;  but  in  certain  subjects,  and  especially  at  certain  periods 
of  life,  muscular  weakness  occurs,  and  the  muscles  are  no  longer  equal 
to  their  task  of  keeping  the  spine  in  its  normal  position  for  any  length 
of  time.  This  is  most  frequently  seen  in  girls  between  the  ages  of  twelve 
and  seventeen — a  period  which  comprises  the  onset  of  menstruation, 
and  the  abandonment  of  the  free  vigorous  life  and  exercises  of  childhood. 
It  is  a  period  often  marked  by  a  predilection  for  sedentary  habits,  the 
semi-recumbent  position,  confinement  to  heated  rooms  and  the  keeping 
of  late  hours,  together  with  the  assumption  of  tight-fitting  garments 
which  hinder  the  free  play  of  the  muscles  so  essential  to  the  proper 
development  of  the  trunk.  The  condition  is  still  further  aggravated  if 
ansemia  be  present ;  fatigue  is  then  produced  by  any  slight  muscular 
exertion,  and  this  also  leads  to  avoidance  of  active  exercise  and  the 
assumption  of  faulty  attitudes. 

One  of  the  most  potent  factors  in  the  production  of  scoliosis  is  over- 
fatigue,  due  to  prolonged  standing,  sitting,  or  walking.  Nursemaids,  type- 
writers, school  children  continuously  engaged  in  reading,  writing,  or  piano- 
playing,  occupations  which  involve  the  habitual  assumption  of  a  faulty 
position  of  the  spine,  may  all  develop  scoliosis,  should  the  general  health 
be  such  as  to  cause  enfeeblement  of  the  muscles.  A  similar  result  occurs 
in  girls  who  are  in  the  habit  of  riding  on  horseback  for  periods  long 


SCOLIOSIS  4o7 

enough  to  cause  fatigue  to  the  muscles  of  the  back,  and  to  lead  to  a  faulty 
position  of  the  spine.  It  is  on  this  account  that  rapidly  growing  weakly 
girls  are  recommended  to  ride  on  opposite  sides  of  the  horse  on  alternate 
days,  so  as  to  exercise  equally  the  erector  muscles  on  the  two  sides. 
Scoliosis  may  also  be  produced  in  children  if  they  are  always  carried  on 
the  same  arm,  whereas  if  they  are  carried  first  upon  one  arm  and  then 
upon  the  other,  no  harm  results  either  to  the  nurse  or  the  child. 

Cases  in  which  the  deformity  is  secondary  to  other  affections  of  the 
spine  or  thorax. — Here  the  curvature  of  the  spine  is  mechanical,  and 
is  produced  by  some  alteration  in  that  structure  itself,  or  in  the  capacity 
of  the  thorax.  Familiar  examples  are  lateral  curvature  secondary  to 
empyema,  collapse  of  the  lung,  rickets,  and  tuberculous  disease  of  the 
spine,  etc. 

PATHOLOGICAL  CHANGES.— After  a  time  organic  changes 
take  place  in  the  ligaments  and  the  bones,  so  that  a  curvature,  which 
at  first  could  be  easily  rectified  by  appropriate  position,  becomes  more 
and  more  permanent.  The  first  change  that  occurs  is  an  alteration  in 
length  of  the  various  fibrous  structures  on  the  two  sides,  those  upon  the 
convexity  becoming  stretched,  and  those  upon  the  opposite  side  being 
proportionately  shortened.  In  advanced  cases,  the  vertebral  bodies 
themselves  become  altered  so  that  each  is  somewhat  wedge-shaped,  the 
base  of  the  wedge  being  directed  towards  the  convexity  of  the  curve. 
The  surfaces  of  the  various  articular  processes  also  become  altered  in 
direction.  These  bony  changes  are  permanent,  and  account  for  the 
intractability  of  the  severe  cases. 

SYMPTOMS. — The  symptoms  of  scoliosis  may  be  divided  into 
the  objective  and  subjective  symptoms. 

Objective  Symptoms. — Sometimes  the  spine  is  bent  to  one  side  in  a 
large  single  C-shaped  curve,  which  may  either  involve  the  entire  vertebral 
column,  or  may  be  confined  to  the  lumbar  or  dorsal  regions.  Should  a 
curvature  of  this  kind  be  at  all  marked,  it  will  be  necessary  for  one  or  more 
compensatory  curves  to  be  formed  in  the  opposite  direction  for  the 
adjustment  of  the  centre  of  gravity  of  the  body,  as  otherwise  the  erect 
position  could  not  be  maintained.  These  compensatory  curves  have 
their  curvature  in  the  opposite  direction  to  the  main  one,  and  are  smaller 
in  extent  than  the  primary  curve. 

In  the  common  form  of  scoliosis  there  are  generally  two  curves  which 
have  their  convexities  in  opposite  directions,  so  that  the  spine  somewhat 
resembles  the  letter  S-  Of  these,  one  is  usually  called  the  primary  and 
the  other  the  secondary  curve.  The  primary  curve  cannot  always  be 
clearly  distinguished,  but  a  fair  idea  can  generally  be  gained  by  consider- 
ing the  mechanism  of  the  formation  of  the  curvature.  If  due  to  an  in- 
equality in  length  of  the  lower  extremities,  the  primary  curve  will  be  in 
the  lumbar  or  lower  dorsal  region,  whilst  that  in  the  upper  dorsal  is 
merely  compensatory ;  on  the  other  hand,  if  the  curvature  be  due  to 


4o8  DEFORMITIES 

faulty  position,  the  primary  curve  is  usually  in  the  upper  dorsal  region, 
whilst  the  compensatory  curve  is  below  it  When  the  primary  curve  is 
very  marked  there  may  be  three  or  even  more  curves  in  the  spine  ;  the 
primary  curve  is  then  generally  very  acute,  and  at  either  end  of  it  there 
is  a  compensatory  curve.  This  is  usually  the  case  in  severe  dorsal  curva- 
ture, when  there  is  a  compensatory  curve  in  the  cervical  and  another  in 
the  lumbar  region.  In  some  cases  certain  spinous  processes  may  project 
markedly  backwards  ;  the  case  then  requires  careful  examination  in 
order  to  distinguish  it  from  tuberculous  disease. 

A  marked  objective  symptom  is  asymmetry  of  the  thorax.  The 
shoulder  upon  the  side  of  the  convexity  of  the  curve  is  higher  than  its 
fellow  ;  the  intercostal  spaces  are  considerably  wider  on  that  side, 
whilst  they  are  narrowed  upon  the  side  of  the  concavity.  The  spinous 
processes  deviate  from  the  middle  line.  The  distance  between  the  lower 
ribs  and  the  crest  of  the  ilium  on  one  side  is  much  increased,  whilst 
there  is  a  deep  fold  in  the  corresponding  situation  on  the  opposite  side. 
The  total  body  height  is  diminished. 

When  there  is  much  rotation  of  the  bodies  of  the  vertebrae,  the  thorax 
undergoes  extensive  deformity ;  the  ribs  on  the  side  of  the  convexity 
of  the  curve  are  carried  backwards,  whilst  they  travel  in  a  forward 
direction  on  the  opposite  side.  The  shape  of  the  two  sides  of  the  thorax 
is  therefore  greatly  altered.  On  the  side  of  the  convexity  the  vertical 
measurement  of  the  thoracic  cavity  is  increased,  owing  to  the  separation 
of  the  ribs,  but  the  transverse  one  is  lessened.  On  the  side  of  the  con- 
cavity the  reverse  is  the  case,  but  probably  the  cubic  capacity  on  the 
two  sides  is  but  slightly  altered.  The  angles  of  the  ribs  on  the  side  of 
the  convexity  become  more  acute,  whilst  those  on  the  opposite  side 
either  remain  unaltered  or  become  more  obtuse.  The  result  is  a  pro- 
minent ridge  upon  the  side  of  the  convexity  formed  by  the  angles  of  the 
ribs  with  the  erector  muscles  over  them.  The  clavicle  on  that  side  may 
have  its  curves  increased,  and  cases  are  recorded  in  which  the  sternal 
end  has  become  dislocated.  The  scapula  on  the  side  of  the  convexity  is 
carried  backwards  to  a  plane  posterior  to  its  fellow,  and  is  raised  and  some- 
times tilted.  The  arm  on  the  opposite  side  hangs  away  from  the  thorax. 

Subjective  Symptoms. — The  subjective  symptoms  are  usually  slight, 
but  may  become  exaggerated  in  neurotic  subjects  or  in  those  in  whom 
the  deformity  is  extreme.  There  is  aching  pain,  and  a  feeling  of  weariness 
in  the  back  and  loins,  sometimes  extending  down  to  the  thighs.  When 
the  deformity  has  lasted  long  and  extensive  bony  changes  have  occurred, 
there  may  be  considerable  pain,  partly  from  the  pull  upon  the  stretched 
ligaments  and  partly  from  direct  pressure  upon  the  nerves  or  the 
viscera.  The  lung  may  be  compressed  upon  the  side  of  the  convexity, 
and  patients  with  long-standing  dorsal  curvature  are  apt  to  suffer  from 
severe  bronchitis ;  the  heart  may  also  be  displaced,  and  the  liver  and 
spleen  unduly  pressed  upon. 


SCOLIOSIS  409 

There  should  be  no  difficulty  in  diagnosing  this  condition  from  tuber- 
culous disease,  as  in  scoliosis  there  is  no  rigidity  and  no  tenderness  on 
pressure  over  the  affected  vertebrae  or  on  jarring  down  through  the 
head.  Moreover,  except  in  rare  cases,  there  is  no  projection  backwards 
of  the  vertebrae. 

EXAMINATION.— In  examining  a  subject  of  scoliosis  in  order  to 
determine  the  treatment  to  be  adopted,  a  certain  routine  should  be  gone 
through. 

The  patient  should  be  stripped  to  the  hips  and  should  stand  in  a 
position  of  ease  with  her  back  to  the  surgeon,  the  garments  being  fastened 
with  a  safety-pin  to  prevent  them  slipping  down  and  to  avoid  the  constant 
changes  of  position  that  accompany  the  endeavours  to  hold  them  up. 
The  spinous  processes  should  then  be  marked  upon  the  skin  with  a  carbon 
pencil  and  a  sheet  of  paper  pressed  over  them  so  as  to  obtain  a  per- 
manent record ;  the  marks  made  by  the  pencil  will  be  transferred  to 
the  paper,  which  can  be  varnished  and  kept  for  reference.  A  slight  de- 
viation of  the  spine  is  best  detected  by  letting  fall  a  plumb-line  from  the 
spinous  process  of  the  seventh  cervical  vertebra.  Any  deviation  of  the 
spinous  processes  from  the  vertical  can  be  measured. 

The  next  important  point  is  to  ascertain  whether  there  is  any  obliquity 
of  the  pelvis.  The  patient  is  turned  round,  and  the  surgeon,  standing  or 
kneeling  in  front,  places  a  thumb  upon  each  anterior  superior  iliac  spine 
and  notes  whether  they  are  on  the  same  horizontal  level ;  in  case  of 
doubt,  the  patient  should  stand  quite  erect,  with  the  feet  together,  and 
the  length  of  the  lower  extremities  should  then  be  measured  from  the 
anterior  superior  spine  to  the  floor  on  each  side.  The  presence  of  flat 
foot  or  knock  knee  should  also  be  looked  for. 

The  next  point  is  to  determine  what  amount  of  alteration  can  be 
made  in  the  curvature  by  alteration  in  position ;  in  other  words,  the 
flexibility  of  the  spinal  column  is  tested.  The  patient  should  be  directed 
to  hold  herself  as  erect  as  possible,  and  any  alteration  in  the  curvature 
is  then  compared  with  the  measurements  taken  in  the  position  cf  rest. 
In  slight  curvatures  marked  improvement  is  produced  by  the  effort  of 
standing  to  attention.  Should  the  curvature  be  due  to  inequality  in 
the  length  of  the  lower  extremities,  suitable  blocks  must  be  placed 
beneath  the  shortened  limb  so  as  to  make  the  pelvis  horizontal,  and 
the  effect  upon  the  curvature  noted.  In  early  cases  this  will  obliterate  it 
entirely. 

The  patient  should  next  be  suspended  by  the  hands  from  a  bar,  with  the 
feet  just  off  the  ground,  so  that  the  entire  weight  of  the  body  is  borne  by 
the  arms.  A  more  accurate  method  is  to  use  a  trapeze  with  two  bars,  the 
upper  one  being  three  inches  above  the  lower,  hung  just  high  enough  to 
swing  the  patient  free  of  the  ground.  The  lower  bar  is  grasped  with  the 
hand  upon  the  side  of  the  convexity,  whilst  the  upper  is  laid  hold  of  with 
the  other ;  this  pulls  upon  the  spinal  column  and  tends  to  straighten 


4io 


DEFORMITIES 


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SCOLIOSIS  4II 

the  curve.  The  positions  of  the  spinous  processes  are  now  noted  and 
compared  with  those  observed  in  the  standing-at-ease  position.  In 
young  children  the  bar  may  be  dispensed  with,  the  child  being  lifted 
from  the  ground  by  the  arms. 

The  patient  should  next  be  made  to  stand  erect  and  bend  forward 
slowly  until  the  fingers  touch  the  toes.  The  amount  of  rotation  can  then  be 
estimated  by  noticing  the  asymmetry  of  the  ribs.  If  it  be  desired  to 
record  this,  a  tracing  of  the  contour  of  the  posterior  aspect  of  the  ribs 
can  be  made  with  a  pleximeter.  This  will  enable  the  surgeon  to  differen- 
tiate between  a  case  of  lateral  curvature  and  one  of  true  scoliosis.  In  the 
patient  shown  in  Fig.  141  A  there  was  a  marked  difference  in  the  level  of 
the  shoulders  ;  on  making  the  child  stoop  down,  however,  the  two  sides 
of  the  thorax  are  quite  symmetrical,  showing  that  no  rotation  of  the 
vertebrae  was  present.  In  Fig.  141  C  is  shown  the  condition  found  in  a 
case  of  true  scoliosis  with  considerable  rotation  of  the  vertebrae.  Cases 
are  also  seen  in  which  there  is  very  little  curvature  present,  but  on 
making  the  patient  stoop  advanced  rotation  is  at  once  evident ; 
deformity  of  this  kind  is  a  symptom  of  bad  import,  as  it  is  more  difficult 
to  rectify  than  the  ordinary  lateral  curvature. 

PROGNOSIS. — The  method  of  examination  just  described  is  of 
great  importance  both  in  prognosis  and  in  treatment,  as  it  shows  how 
much  flexibility  remains  in  the  spine  and  gives  a  good  indication  of  the 
best  result  that  can  be  expected  from  treatment.  When  suspension 
fails  to  obliterate  the  curve  entirely,  we  may  fairly  conclude  that  liga- 
mentous  or  even  bony  changes  have  taken  place  in  the  spinal  column, 
and  that  therefore  perfect  restoration  of  the  erect  position  is  not  likely 
to  result  from  treatment.  On  the  other  hand,  a  hopeful  prognosis  may  be 
given  in  those  cases  in  which  the  spine  straightens  out  completely,  and 
the  chances  are  that,  with  proper  care  and  suitable  treatment,  the  curve 
may  be  entirely  obliterated. 

When  called  upon  to  give  a  definite  prognosis  in  these  cases,  the 
surgeon  must  remember  that  a  large  number  of  the  minor  degrees  are 
of  a  purely  temporary  nature,  depending  probably  upon  some  defect  in 
the  general  health,  and  that  the  curvature  will  either  be  arrested  or 
cured  as  the  muscles  recover  their  tone.  The  disparity  between  the 
number  of  cases  of  slight  lateral  curvature  coming  under  notice  in  early 
life  and  those  adult  cases  in  which  the  curvature  amounts  to  actual 
deformity  proves  that  something  of  this  kind  probably  occurs  in  the 
majority  of  cases.  The  cases  most  prone  to  undergo  spontaneous  cure 
are  those  in  which  there  are  two  slight  equal  curves  rather  than  a  single 
large  C-shaped  one,  which  tends  to  increase  and  to  result  in  important 
rotation  changes  since  there  is  no  compensation. 

When  the  curvature  is  due  to  inequality  in  length  of  the  two  ex- 
tremities the  cases  are  very  amenable  to  treatment  if  seen  within  a 
reasonable  time,  and  a  good  result  can  generally  be  obtained.  The 


412  DEFORMITIES 

opposite  is  the  case  when  the  curvature  is  the  sequela  of  some  chest 
disease,  such  as  empyema. 

Perhaps,  however,  the  most  important  feature  in  the  prognosis  is  the 
condition  of  the  patient's  health.  Scoliosis  associated  with  profound 
anaemia  is  most  difficult  to  treat,  and  little  beneficial  effect  upon  the 
curvature  is  to  be  looked  for  unless  the  anaemia  can  be  treated  with 
success.  The  most  difficult  cases  of  all  are  in  anaemic  girls  about  the 
age  of  puberty  who  also  suffer  from  dysmenorrhoea  ;  when  these  con- 
ditions are  combined  with  a  neurotic  taint,  the  case  may  prove  intractable. 

The  age  of  the  patient  at  the  onset  of  the  curvature  is  of  great  im- 
portance. In  a  very  young  child  the  vertebrae  are  soft  and  easily  moulded, 
and  there  is  a  long  period  during  which  the  spine  may  undergo  serious 
structural  alterations  unless  it  be  maintained  in  proper  position.  When 
the  disease  begins  only  a  short  time  before  ossification  is  complete, 
however,  there  is  little  time  for  great  changes  to  take  place  in  the 
vertebrae.  The  curvature  will  therefore  develop  much  more  slowly — 
an  important  point  with  regard  to  treatment. 

TREATMENT. — The  question  of  prophylaxis  must  always  be  borne 
in  mind  by  those  who  have  charge  of  patients  who  are  likely  to  become 
the  subjects  of  this  affection. 

Prophylaxis. — When  there  is  obliquity  of  the  pelvis.— Any  patient 
with  inequality  in  the  length  of  the  lower  extremities  should  receive 
treatment  directed  to  remedying  the  resulting  obliquity  of  the  pelvis. 
When  a  patient  has  been  the  subject  of  hip  disease  and  is  left  with  de- 
formity and  shortening  of  the  limb,  the  deformity  must  be  remedied  as 
far  as  possible,  and  a  high  boot  must  be  worn  on  the  affected  limb  so 
as  to  make  the  two  limbs  the  same  length.  Congenital  dislocation  of 
the  hip  should  receive  appropriate  treatment  (see  p.  394).  Apparatus 
will  be  required  for  cases  of  arrest  of  development  following  infantile 
paralysis,  whilst  genu  valgum  and  flat  foot  should  be  treated  upon  the 
lines  laid  down  in  Chapters  XVIII.  and  XV. 

When  heavy  weights  are  carried  upon  one  side. — The  obvious  pro- 
phylactic remedy  here  is  to  see  that  any  weight  likely  to  produce  curva- 
ture is  carried  alternately  upon  the  two  sides.  Nursemaids  should  be 
told  to  carry  children  alternately  upon  either  arm — an  order  that  will 
benefit  both  child  and  nurse  alike.  \Vhen  an  arm  has  been  lost,  the 
patient  should  be  forbidden  to  carry  heavy  weights  ;  if  enough  of  the 
limb  remains  to  allow  an  artificial  limb  to  be  fitted,  the  weight  should 
be  carried  alternately  by  the  natural  and  the  artificial  limb. 

When  there  is  weakness  of  the  spinal  muscles. — The  ordinary  rules 
for  personal  hygiene  must  be  insisted  upon,  but  there  are  certain  special 
points  to  which  attention  should  be  paid.  Weakly  children  or  those 
suffering  from  rickets  should  be  carried  in  the  horizontal  position  in  the 
nurse's  arms  ;  they  should  never  be  carried  upright  even  when  they 
have  become  strong  and  healthy  unless  they  can  be  carried  alternately 


SCOLIOSIS  4I3 

on  either  arm.  Massage  of  the  back  muscles,  with  applications  of  sea- 
water  douches  is  of  value.  The  massage  should  be  done  for  about  a 
quarter  of  an  hour  at  a  time  night  and  morning,  and  should  be  followed 
by  a  sea-water  douche. 

Special  care  is  needed  in  the  case  of  rapidly  growing  girls  who  are 
nearing  the  period  of  puberty.  All  heavy  or  constricting  garments  about 
the  chest  or  abdomen  which  interfere  with  the  free  play  of  the  thoracic, 
abdominal,  and  spinal  muscles  should  be  forbidden,  and  the  child  should 
be  encouraged  to  play  games,  to  lead  a  healthy  outdoor  life,  and  to  go 
through  a  mild  gymnastic  course.  Sedentary  habits,  the  desire  to  remain 
in  the  house  in  the  recumbent  position  reading  novels  should  be  checked, 
and  in  fact  the  life  of  the  two  sexes  should  be  assimilated  as  much  as 
possible.  Girls  who  ride  on  horseback,  and  in  whom  there  is  any  tendency 
to  curvature,  should  ride  astride  or  upon  a  reversible  saddle  so  that  the 
exercise  can  be  taken  on  alternate  sides ;  the  rides  should  never  be 
long  enough  to  produce  fatigue.  Corsets  of  any  kind  are  bad,  and  if 
employed  should  not  be  allowed  to  compress  the  chest. 

This  is  about  the  period  of  life  at  which  curvature  is  apt  to  occur  as 
a  result  of  faulty  position.  Some  attention  has  been  directed  to  the 
possibility  of  producing  lateral  curvature  by  faulty  positions  during 
sleep.  Many  children  sleep  upon  the  back,  and  this  is  obviously  the 
best  position.  A  large  number,  however,  lie  upon  one  side,  and  it  has 
been  said  that,  if  a  child  is  in  the  habit  of  lying  more  upon  one  side  than 
the  other,  this  may  produce  curvature  of  the  spine.  This  is  probably  an 
exaggerated  view,  but  it  is  well  to  encourage  sleeping  upon  alternate 
sides  if  the  child  be  unable  to  sleep  upon  the  back.  The  mattress  should 
be  firm  and  a  feather-bed  should  be  avoided ;  the  head  should  not  be 
raised  unduly. 

The  positions  usually  adopted  by  children  at  school  when  sitting  at  a 
desk,  writing,  reading,  or  drawing,  or  when  playing  the  piano,  are  often 
faulty,  and  calculated  to  produce  scoliosis.  The  child  is  generally  either 
seated  upon  a  form  without  any  back,  or  upon  a  chair,  the  back  of  which 
is  too  straight  and  not  high  enough,  whilst  the  seat  is  too  far  from  the 
ground,  and  there  is  a  want  of  proportion  between  the  height  of  the 
desk  and  the  chair  or  form  upon  which  the  child  sits.  The  result  is  that 
the  child  soon  gets  tired,  brings  the  pelvis  to  the  edge  of  the  chair  in 
order  to  enable  the  feet  to  touch  the  ground  and  support  him,  and  he  is 
often  obliged  to  tilt  the  pelvis  in  order  to  bring  one  foot  into  contact 
with  the  floor.  The  spine  is  thus  unsupported,  and  the  child  either  stoops 
forward  or  bends  to  one  side  so  as  to  rest  his  elbow  upon  the  desk  at 
which  he  is  writing. 

The  want  of  proper  proportion  between  the  height  of  the  seat  and 
the  desk  plays  a  very  important  part,  for,  when  the  desk  is  too  high,  the 
right  arm  has  to  be  unduly  elevated  if  the  child  wishes  to  write,  whilst 
if  the  desk  be  too  low  it  has  to  be  unduly  depressed  and  the  left  shoulder 


414 


DEFORMITIES 


is  consequently  raised.     This  may  lead  to  the  development  of  a  marked 
lateral  curvature  in  a  weakly  child. 

The  chief  requisites  for  a  school  seat  and  desk  will  be  seen  on  reference 
to  Fig.  142.  The  back  of  the  chair  should  extend  upwards  as  high  as  the 
shoulders,  and  should  be  prolonged  high  enough  to  support  the  head  if 
the  child  suffers  from  a  weak  spine.  The  seat  should  be  at  such  a  height 
from  the  ground  that  the  feet  rest  easily  upon  the  floor,  or  upon  a  foot- 
rest  inclined  at  an  angle  of  about  20°.  The  breadth  of  the  chair-seat 
should  be  equal  to  the  length  of  the  child's  thighs,  and  there  should  be 
just  room  between  the  seat  of  the  chair  and  the  under  surface  of 

the  desk  for  the  thighs. 
The  precise  measure- 
ments usually  given  are 
that  the  lower  edge  of 
the  desk  should  be  an 
eighth  of  the  height  of  a 
girl  and  a  one-seventh  that 
of  a  boy  above  the  seat 
of  the  chair.  The  writ- 
ing desk  should  have  a 
gentle  slope  so  as  not  to 
force  the  child  to  bend 
forward  too  much  when 
he  wishes  to  read  or 
write. 

Any  defect  of  vision 


FIG.     142. A    WELL-DESIGNED     DESK    AND     SEAT.         Both    desk 

and  seat  can  be  raised  or  lowered  about  4  inches. 


suitable  glasses  so  as  to 
avoid  all  necessity  of 
stooping  over  the  desk, 


which    is    likely    to    act 

injuriously  in  producing  curvature.  Exercises  to  develop  and  strengthen 
the  chest  muscles  should  be  prescribed  unless  the  child  be  obviously 
perfectly  robust.  Massage  will  also  be  called  for  when  there  is  any  actual 
weakness  of  the  spine  ;  this  important  factor  in  treatment  should  never 
be  omitted.  The  exercises  are  dealt  with  on  p.  423. 

When  there  has  been  disease  within  the  thorax,  etc.  —  In  some  of  these 
cases  little  can  be  done  in  the  way  of  prophylaxis.  In  cases  of  Pott's 
disease  and  rickets,  appropriate  treatment  for  the  disease  will  stave  off 
the  onset  of  scoliosis.  After  empyema  or  collapse  of  the  lung,  some 
curvature  is  inevitable  ;  it  may,  however,  be  minimised  by  prescribing 
exercises  directed  to  bending  the  spine  in  a  direction  opposite  to  that  in 
which  the  curvature  is  expected  to  take  place  ;  these  exercises  should 
be  begun  before  any  curvature  has  been  detected  and  should  be  persevered 
with  for  many  years. 


SCOLIOSIS  415 

When  Scoliosis  has  developed.— These  cases  may  be  divided 
into  four  large  groups  :  (a)  the  curvatures  of  infancy,  (b)  those  occurring 
during  childhood,  (c)  those  occurring  during  the  period  of  adolescence, 
and  (d)  those  occurring  after  growth  is  complete. 

The  Scoliosis  of  Infancy. — The  remarks  made  with  reference  to  the 
treatment  of  kyphosis  (see  p.  404)  will  apply  largely  to  this  condition.  The 
general  health  requires  attention  ;  rickets  must  be  treated  by  proper  feed- 
ing, hygienic  measures,  and  the  regular  administration  of  appropriate 
drugs  (see  Vol.  II.).  The  child  should  be  kept  in  the  horizontal  position, 
either  in  the  nurse's  arms  or  upon  a  suitably  padded  tray  or  basket. 
After  the  first  year,  the  back  support  recommended  for  kyphosis  (see 
p.  404)  may  be  employed,  but  recumbency  must  still  be  insisted  upon,  so 
as  to  relieve  the  back  from  the  superincumbent  weight.  The  child  should 
always  be  sent  to  the  country  or  the  seaside  for  a  considerable  period 
if  possible,  and  massage  to  the  back  muscles  should  be  employed  night 
and  morning. 

Walking  should  be  discouraged ;  mothers  are  anxious  for  the  child 
to  begin  to  walk  early,  but  the  importance  of  the  recumbent  position 
should  be  pointed  out,  and  attempts  at  walking  prohibited.  The  child 
should  be  encouraged  to  sleep  upon  the  back,  and  may  if  necessary  be 
fastened  down  upon  a  suitably  padded  wicker  tray  in  that  position. 
Special  bed  splints  are  sold  for  this  purpose  and  may  be  used  if  preferred. 
Should  there  be  a  marked  curvature,  however,  the  lateral  position  may 
be  substituted  for  the  dorsal,  the  child  being  taught  to  lie  upon  the  side 
of  the  convexity  of  the  curve  in  the  dorsal  region,  with  a  firm  pillow  or 
small  bolster  interposed  between  the  mattress  and  the  thorax,  with  the 
object  of  unfolding  the  curve.  The  mattress  should  be  firm ;  a  feather 
bed  should  be  avoided,  and  the  child  should  sleep  with  the  head  supported 
by  one  small  pillow. 

The  Scoliosis  of  Childhood. — Great  care  has  to  be  exercised  in 
the  treatment  of  curvatures  during  this  period  of  life,  for,  although  on  the 
one  hand  the  spine  is  extremely  flexible,  and  therefore  can  be  easily 
influenced  by  treatment,  this  fact  may  be  a  source  of  actual  danger, 
because  the  curve  if  neglected  will  lead  to  such  marked  distortion 
of  the  bones  when  they  become  fully  ossified  as  to  render  treatment 
very  difficult. 

Removal  of  the  Cause. — Before  proceeding  to  attack  the  curvature 
itself,  any  cause  that  may  originate  or  keep  up  the  vicious  position  should 
be  eliminated.  Any  obliquity  of  the  pelvis,  due  to  inequality  in  the 
length  of  the  lower  extremities,  must  be  remedied  by  suitable  means, 
such  as  boots  or  operation.  Any  vicious  attitude  acquired  while  sitting 
or  standing  at  lessons,  or  even  in  playing  games,  must  be  carefully  in- 
quired for  and  forbidden,  while  some  other  attitude  or  game  which  tends 
to  rectify  the  faulty  position  thus  produced  should  be  substituted.  Any 
optical  defects,  such  as  myopia,  should  receive  treatment ;  adenoids  or 
enlarged  tonsils  should  be  removed. 


416  DEFORMITIES 

Medicinal  Treatment. — In  addition  to  this,  the  general  health  must 
receive  attention,  as  it  is  extremely  common  to  find  some  physical 
ailment  in  this  group  of  cases.  Of  these  the  principal  is  anaemia  ; 
dyspepsia  or  constipation  should  receive  suitable  treatment.  The  diet 
should  be  abundant,  light,  and  digestible  ;  cod  liver  oil  should  be  given 
when  the  child  is  particularly  weakly.  The  patient  should  be  in  the 
fresh  air  as  much  as  possible  in  the  country  or  at  the  seaside,  and  the 
size  and  ventilation  of  the  living  and  sleeping  rooms  shou]d  receive  due 
attention. 

The  most  important  point,  however,  is  the  avoidance  of  fatigue,  which 
rapidly  enfeebles  the  muscles.  The  treatment  of  the  curvature  itself 
will  require  a  nice  discrimination  between  rest  and  exercises,  the  latter 
being  designed  to  strengthen  the  muscles,  the  former  to  avoid  tiring 
them.  Children  at  this  period  of  life  should  lead  a  healthy,  active,  out- 
door life.  Sitting  and  standing  at  lessons  must  be  discouraged  in  favour 
of  outdoor  exercise,  which,  by  improving  the  general  health  and  the 
muscular  tone,  helps  to  cure  the  curvature.  The  child  may  remain  at 
school  provided  that  she  sits  upon  a  proper  seat  before  a  well- 
constructed  desk  (see  p.  414)  and  has  proper  rest  combined  with  suitable 
gymnastic  exercises  (vide  infra] ;  the  advantage  of  allowing  her  to  remain 
at  school  is  that  she  will  probably  be  more  amenable  to  the  discipline 
required  for  the  proper  performance  of  the  exercises. 

Recumbency. — Rest  in  the  recumbent  position  must  always  be 
insisted  upon.  The  period  of  rest  must  be  regulated  by  the  particular 
features  of  the  case,  but  in  nearly  all  cases  at  least  two  hours  a  day  are 
required.  It  is  well  to  divide  this  period  up  into  two  equal  portions  and 
to  order  the  patient  to  rest  upon  a  couch  for  an  hour  about  midday  and 
for  another  hour  in  the  late  afternoon.  If  the  patient  will  tolerate  it, 
the  prone  position  is  better  than  the  supine ;  many  children,  however, 
strongly  object  to  this,  and  there  is  no  real  objection  to  employing  the 
other.  As  a  compromise,  the  child  may  be  placed  first  in  the  prone  posi- 
tion until  it  becomes  too  irksome,  when  the  supine  position  may  be 
assumed.  The  rest  may  be  taken  upon  an  ordinary  hard  couch  ;  it  is 
better,  however,  to  have  a  spinal  couch  so  that  the  patient  lies  upon 
a  slightly  inclined  plane. 

Exercises. — Mechanical  exercises  should  always  be  advised  with 
the  view  of  strengthening  the  muscles  generally  and  of  restoring  the 
tone  of  those  to  whose  failure  the  curvature  is  due.  When  the  curvature 
is  only  slight,  little  is  required  beyond  general  muscular  exercises  which 
can  be  carried  out  at  home  under  the  supervision  of  the  parents  or  a 
capable  nurse.  Good  types  of  these  will  be  found  on  p.  423  (see  Series 
A,  B,  C,  E,  F,  G,  I).  They  should  be  practised  daily  for  ten  minutes  to  half 
an  hour  at  a  time  in  the  late  forenoon ;  immediately  after  them  the 
child  should  lie  down  for  the  midday  rest.  Dumb-bell  exercises  may  also  be 
performed  on  rising  in  the  morning  for  five  to  fifteen  minutes  before  dressing. 


SCOLIOSIS  417 

The  dumb-bells  should  not  exceed  a  pound  in  weight  at  the  outset ;  as 
the  patient  becomes  more  used  to  the  exercises,  the  weight  may 
be  increased,  as  may  also  the  length  of  time  during  which  the 
exercises  are  performed.  The  home  exercises  recommended  above  may 
be  done  with  dumb-bells,  and  are  then  equivalent  to  exercises  carried 
out  against  resistance. 

Riding  exercise  is  useful,  so  long  as  it  is  not  allowed  to  cause  fatigue. 
A  girl  should  ride  upon  the  same  side  of  the  horse  as  that  upon  which 
the  convexity  of  the  curve  is,  so  that  there  will  be  a  tendency  to  open 
out  the  curvature.  In  the  early  stages  of  the  treatment  it  is  important 
to  impress  upon  the  parents  that,  when  any  of  these  forms  of  exercise 
cause  fatigue,  they  should  be  stopped  at  once  and  the  child  allowed  to  rest. 

Massage. — Massage  to  the  muscles  of  the  back  should  never  be 
omitted.  It  should  be  employed  twice  a  day  for  about  half  an  hour, 
after  breakfast  and  before  going  to  bed. 

When  the  curvature  is  very  marked,  it  will  be  necessary  to  employ 
special  exercises  and  other  procedures  designed  to  act  directly  upon  the 
curvature,  in  addition  to  those  which  aim  at  improving  the  muscles 
generally.  The  case  will  then  be  closely  allied  to  those  about  to  be 
described  in  the  following  paragraphs,  and  the  exercises  will  be  the  same. 

The  Curvatures  of  Adolescence.— The  treatment  of  the  cur- 
vatures which  occur  between  puberty  and  the  final  cessation  of  growth 
often  presents  considerable  difficulty  owing  to  the  impossibility  of  in- 
sisting upon  the  healthy  outdoor  life  which  it  is  comparatively  easy 
to  secure  for  younger  patients. 

The  general  indications  for  treatment  are  similar  to  those  for  the  pre- 
ceding group.  Any  mechanical  cause  must  be  removed,  and  the  general 
health  attended  to;  menstrual  irregularities,  anaemia,  or  constipation 
must  be  treated ;  careful  personal  hygiene  should  be  insisted  upon,  and  the 
patient  compelled  to  take  regular  exercise,  to  avoid  late  hours  and  hot, 
ill- ventilated  rooms,  and  to  take  simple,  regular,  and  easily  digested  meals. 
Fatigue  and  faulty  positions  should  be  avoided,  and  any  desks,  chairs,  or 
music-stools  that  the  patient  uses  must  be  made  to  suit  the  individual 
requirements  of  the  case.  A  cold  sponge  bath  in  summer  and  a  tepid  one 
in  winter  should  be  taken  on  rising  in  the  morning,  and  the  back  muscles 
should  be  massaged  and  developed  by  the  exercises  which  will  presently 
be  described.  The  following  breathing  exercises  are  also  good  : 

1.  The  patient  stands  erect  with  the  arms  stretched  out  at  right  angles 
to  the  body  and  the  palms  downwards. 

2.  The  arms  are  rotated  outwards  so  as  to  bring  the  palms  upwards 
and  put  the  pectoral  muscles  on  the  stretch. 

3.  The  arms  are  now  brought  vertically  above  the  head,  the  patient  in- 
spiring meanwhile  through  the  nose;  the  breath  is  held  while  the  patient 
counts  five  and  then  is  allowed  to  escape  as  the  arms  fall  to  the  side  of 
the  body. 


EE 


DEFORMITIES 


The  treatment  of  the  curvature  \vill  vary  according  to  the  flexibility  of 
the  spine — that  is  to  say,  according  to  the  straightening  produced  when 
the  patient  is  suspended.  We  may  divide  these  cases  into  (a)  those  in 
which  the  curve  can  be  obliterated,  (ft)  those  in  which  the  curve  can  be 
ameliorated  but  not  entirely  obliterated,  and  (y)  those  in  which  no  altera- 
tion can  be  produced. 

(a)  The  eases  in  which  the  curve  can  be  obliterated. — Here  the  pro- 
gnosis is  good,  as  the  muscular  apparatus  is  probably  alone  at  fault,  and 
no  bony  or  ligamentous  changes  have  yet  occurred  in  the  spine.  The 
object  of  the  treatment,  therefore,  is  to  strengthen  the  back  muscles,  and 
thus  enable  them  to  perform  their  function  of  keeping  the  spine  erect. 
One  of  the  most  important  ways  of  doing  this  is  by  suitable  exercises. 

Exercises. — A  multitude  of  different  exercises  have  been  designed  for 

the  treatment  of  these  cases,  many  of 
which  are  extremely  complicated.  There 
are,  however,  no  specific  exercises  for  the 

V.          ^      •        7"  cure  of  this  condition,  and  the  surgeon  can 

easily  design  efficient  ones  for  himself  by 
observing  accurately  the  changes  that 
have  occurred  and  the  muscles  that  are 
at  fault,  and  ordering  movements  which 
will  bring  into  play  the  defective  muscles, 
and  mechanically  rectify  the  physical 
changes  in  the  trunk.  These  exercises 
should  always  be  carried  out  in  the 
presence  of  some  one  whose  business  it 
is  to  see  that  they  are  properly  and  regu- 
larly performed  for  the  requisite  length 
of  time.  The  simplest  plan  is  for  the 
surgeon  to  supervise  the  first  performance 
of  each  group  of  exercises  as  they  are 
taught,  and  to  point  out  to  the  gym- 


FIG.  143. — SKETCH  SHOWING  THE  IN- 
FLUENCE OF  EXERCISES  UPON  POSTURE 
AND  CHEST  CAPACITY.  The  sketch  is 
from  an  actual  pleximeter  tracing.  The 
dotted  line  shows  the  outline  before,  the 
continuous  one  that  after  the  treatment. 


nasium  master  or  to  the  parents  the 
exact  manner  in  which  they  are  to  be 
done.  It  is  well  to  teach  a  fresh  set  of 
exercises  at  each  sitting,  or  each  alternate 
one,  so  as  to  stimulate  the  patient's 

interest  as  much  as  possible  ;  and  when  the  whole  series  has  been 
learnt,  the  performance  should  be  varied  judiciously.  The  exercises 
should  be  so  planned  that  they  are  carried  out  first  in  the  horizontal, 
then  in  the  sitting,  and  finally  in  the  standing  position,  as  the  muscular 
strength  improves.  An  important  point  is  that  many  of  the  exercises 
are  performed  against  resistance,  the  surgeon,  or  some  form  of  elastic 
apparatus,  opposing  the  action  of  the  muscles.  After  the  exercises  are 
over,  the  patient  should  recline  upon  a  couch,  in  the  prone  position,  for  at 


SCOLIOSIS  4IQ 

least  half  an  hour.  The  period  for  which  the  exercises  are  performed 
may  be  gradually  increased,  if  they  are  doing  good  and  no  undue  fatigue 
is  produced. 

At  the  end  of  a  month  or  six  weeks  from  the  commencement  of 
the  treatment,  after  the  simple  exercises  designed  to  improve  the 
muscular  system  generally  have  been  thoroughly  learnt  and  properly 
practised,  the  surgeon  should  ascertain  what  effect  has  been  produced 
upon  the  curvature.  Should  it  be  found,  as  it  probably  will  be  in  early 
cases,  that  the  curvature  has  almost  disappeared,  and  that  the  patient 
can  hold  herself  erect  without  any  trouble,  little  else  is  needed  beyond 
continuance  of  the  treatment  already  adopted.  Should  the  curvature 
still  persist,  special  exercises  and  'postures'  (see  Figs.  144-5)  designed 
to  open  out  the  curve  will  be  required. 

The  object  of  postural  treatment  is  to  restore  the  spine  to  its  normal 
condition  or  even  to  over-correct  the  deformity  slightly.  The  posture 
employed  must  be  adapted  to  the  individual  case,  only  those  being  chosen 
which  correct  the  deformity  most  completely.  For  example,  the  follow- 
ing postures  will  be  found  useful  for  a  patient  suffering  from  a  dorsal 
curvature  which  is  convex  to  the  right  and  has  compensatory  cervical 
and  lumbar  curves  which  are  convex  to  the  left.  The  head  is  carried  well 
back  and  held  erect.  The  patient  then  puts  the  left  hand  at  the  back 
of  the  neck,  with  the  fingers  over  the  spine  and  the  thumb  resting  about 
the  middle  of  the  sterno-mastoid,  and  thrusts  the  elbow  forwards  and  to 
the  left  so  as  to  draw  the  scapula  away  from  the  middle  line.  This  exerts 
traction  on  the  rhomboids  and  tends  to  pull  the  spines  of  the  dorsal 
vertebrae  to  the  left.  The  patient's  right  hand  is  now  placed  upon  the 
right  side  of  the  thorax,  the  fingers  behind  and  the  thumb  forward,  and 
makes  firm  pressure  over  the  convexity  of  the  dorsal  curve,  while  the  left 
arm  and  elbow  are  kept  well  forward.  The  body  is  now  held  rigidly  in 
the  improved  position  that  this  posture  produces  while  an  attempt  is 
made  to  correct  the  lumbar  curve  by  separating  the  right  leg  from  the  left 
by  a  short  step  outwards  so  as  to  depress  the  right  side  of  the  pelvis.  The 
rotation  of  the  bodies  of  the  lumbar  vertebrae  may  now  be  corrected  by 
taking  a  short  step  forward  with  the  left  foot  so  as  to  twist  the  lumbo- 
sacral  joint  to  the  right. 

While  the  patient  maintains  this  position,  flexion  and  extension  of  the 
spine  should  be  carried  out,  the  head  being  alternately  flexed  with  the  rest 
of  the  trunk  and  kept  extended  by  fixing  the  eyes  on  a  distant  object. 
Another  excellent  posture  is  that  in  which  the  patient  stands  erect  with  the 
hands  upon  the  iliac  crests  and  makes  forcible  pressure  downwards,  as  if 
to  push  a  tight  garment  towards  her  knees.  This  makes  traction  upon 
the  spine  and  straightens  out  the  curves  ;  flexion  and  extension  exercises 
are  then  carried  out  as  before. 

These  exercises  are  first  performed  as  directed,  and  as  the  patient 
becomes  accustomed  to  them  and  can  perform  them  without  fatigue  it 


420 


DEFORMITIES 


is  useful  to  have  them  performed  against  resistance,  the  simplest  way 
of  doing  which  is  to  instruct  the  attendant  to  oppose  the  movements  which 
the  patient  is  endeavouring  to  carry  out,  gently  at  first,  and  with  gradu- 
ally increasing  force  as  the  muscles  grow  stronger.  There  are  several 
forms  of  mechanical  apparatus  which  are  designed  for  the  purpose  of 
carrying  out  movements  against  resistance.  Of  these,  Dowd's  machine 
(see  Fig.  146)  is  a  useful  type,  whilst  there  are  various  other  mechanical 


FIG.  144. — SCOLIOSIS  :  POSTURAL 
TREATMENT.  Posture  described  in 
text  for  correction  of  a  scollosis  with 
dorsal  convexity  to  the  right. 


FIG.    145. — POSTURAL    TREATMEMT 

FOR     ALL    FORMS    OF    SCOLIOSIS.        The 

patient  makes  extension  upon  the 
spine  by  pressing  the  iliac  crests 
downwards. 


exercisers,  such  as  Whiteley's,  etc.,  in  popular  use.     Dumb-bells  are  a 
means  of  doing  the  same  thing  in  a  minor  degree. 

These  simple  movements  are  suited  only  for  cases  in  which  there  is  no 
permanent  distortion  of  the  spine — that  is  to  say,  those  in  which  suspension 
of  the  patient  causes  the  spine  to  become  perfectly  straight.  As  these 
exercises  produce  their  effect  and  obliterate  the  curve,  they  may  be  gradu- 
ally abandoned  in  favour  of  more  simple  home-drill  exercises  designed  to 
improve  the  muscular  system  generally  (see  p.  423)  ;  these  should  be 
practised  at  least  once  daily  for  a  prolonged  period. 


SCOLIOSIS 


421 


A  useful  adjunct  to  this  treatment  is  to  have  the  child  taught  singing, 
which  not  only  develops  various  muscles  of  the  chest  and  back,  but  insures 
proper  expansion  of  the  lungs,  tends  to  obliterate  stooping  habits,  and 
improves  nutrition  generally.  Adenoids  or  enlarged  tonsils,  if  present, 
should  receive  appropriate  treatment.  Mechanical  supports  are  never  neces- 
sary in  this  group  of  cases  ;  indeed,  care  should  be  taken  to  see  that  the 
patient  does  not  wear  stiff  stays  ;  the  utmost  that  should  be  allowed  are 
stays  of  stout  jean  without  bones. 

09)  When  the  curve  can  be 
improved  but  cannot  be  obliter- 
ated.— The  treatment  of  this  class 
is  most  difficult,  because  the  affec- 
tion has  lasted  long  enough  for 
bony  and  ligamentous  changes  to 
have  occurred  which  prevent 
complete  restoration  ;  therefore 
the  treatment  must  have  the 
double  object  of  straightening  the 
spine  as  much  as  possible,  and 
providing  against  subsequent  re- 
lapses, which  are  very  likely  to 
occur  should  the  treatment  be 
abandoned  prematurely. 

Exercises. — The  measures  em- 
ployed to  minimise  the  curvature 
will  be  similar  to  those  for  the 
group  just  described,  but  they 
should  be  persevered  with  more 
energetically  and  should  be  carried 
out  for  a  longer  time  and  at  least 
twice  a  day.  Many  useful  ones 
will  be  found  on  p.  423. 

Another  method  is  the  sus- 
pension of  the  patient  from  two 

parallel  trapeze  bars,  one  being  a  few  inches  higher  than  the  other. 
The  lower  bar,  which  should  be  just  within  reach,  is  grasped  by  the  hand 
on  the  side  of  the  convexity  of  the  curve,  whilst  the  upper  one  is 
grasped  by  the  opposite  hand.  The  patient  may  either  swing  upon  this 
or  merely  hang  free  of  the  ground.  The  object  is  to  allow  the  whole 
weight  of  the  body  to  tell  upon  the  spine  and  thus  to  open  out  the 
curvature ;  this  should  be  combined  with  the  exercises  recommended 
above. 

Spinal  Supports. — The  value  of  mechanical  supports  to  the  spine — 
the  so-called  '  Spinal  Braces ' — in  this  class  of  case  has  been  very  much 
debated,  and  opinion  is  divided  as  to  whether  they  should  be  employed. 


FIG.  146. — DOWD'S  MACHINE.  The  resistance 
against  which  the  exercises  are  performed  can  be 
increased  by  adding  weights  to  the  sliding  brackets. 
Two  machines  are  shown  side  by  side.  (Percy  Leu  it.) 


422 


DEFORMITIES 


In  the  early  stages  no  form  of  brace  or  support  is  permissible  which  tends 
to  keep  the  spinal  column  rigid.  Such  an  apparatus  undoubtedly  supports 
the  spine  to  some  extent,  and  may  therefore  make  the  patient  more 
comfortable  and  relieve  him  of  the  heavy,  dull,  aching  pain  of  which  he 
complains ;  but  its  action  is  most  mischievous,  since  it  is  essential  for  cure 
that  the  muscles  primarily  at  fault  should  be  encouraged  to  perform  their 
function  of  supporting  the  spine,  and  the  confinement  entailed  by  a  tight- 
fitting  jacket  not  only  fails  to  effect  this,  but  even  produces  actual  wasting 
of  the  muscles.  We  are  inclined  to  limit  the  use  of  apparatus  to  cases 
in  which  the  curvature  shows  signs  of  increasing  in  spite  of  vigorous 
treatment  on  the  lines  just  mentioned,  or  to  those  in  which  the  pain  is 


FIG.  147. — '  SPINAL  BRACE  '  FOR  SCOLIOSIS.    This  may  be  taken  to  represent  the 
general  type.     The  various  parts  are  adjustable  by  means  of  nuts.     (Percy  Lewis.) 

severe  and  the  weakness  of  the  muscles  excessive.  Even  then,  the  support 
should  only  be  worn  occasionally  during  the  day,  not  all  day  long,  and 
should  be  as  light  as  is  consistent  with  efficacy.  It  should  be  made  of 
light  steel  bars  taking  purchase  from  a  pelvic  band,  and  should  be  furnished 
with  suitably  padded  springs  so  directed  as  to  apply  pressure  at  the 
requisite  spots — which  are  generally  the  convexity  of  the  curve  and  over 
the  angles  of  the  ribs  where  they  are  rotated  backwards.  The  apparatus 
should  be  so  fashioned  as  only  to  support  the  spine  when  it  is  in  a  position 
of  rest ;  that  is  to  say,  it  should  not  be  sufficiently  tight-fitting  to  keep  the 
spine  immovable  and  therefore  interfere  with  the  proper  action  of  the  back 
muscles.  At  night  no  apparatus  should  be  worn,  attention  being  mainly 
directed  to  the  posture  in  which  the  patient  sleeps.  A  spinal  brace  of 
this  kind  is  shown  in  Fig.  147.  It  requires  careful  adjustment  as  the  curva- 
ture diminishes. 


SCOLIOSIS  423 

(7)  Cases  in  which  the  curvature  cannot  be  diminished  by  suspension.— 
In  these  cases  such  severe  changes  have  taken  place  in  the  spinal  column 
that  it  is  hopeless  to  attempt  any  rectification,  and  the  utmost  that  can 
be  done  is  to  prevent  the  affection  from  increasing  and  to  treat  any 
symptoms,  such  as  pain,  that  may  be  complained  of. 

Spinal  Supports. — In  order  to  prevent  the  increase  of  the  curvature,  a 
support  of  some  kind  is  invaluable,  and  perhaps  the  best  is  a  poroplastic 
jacket  strengthened  with  light  steel  rods  moulded  to  the  thorax  during 
extension  of  the  spine  and  laced  in  position.  This  takes  off  the  super- 
incumbent weight  of  the  thorax,  and  will  often  relieve  the  pain  caused  by 
the  narrowing  of  the  intercostal  spaces  or  the  approximation  of  the  ribs 
to  the  crest  of  the  ilium. 

Even  in  these  cases  muscular  exercises  are  of  value,  and,  if  carried 
out  against  resistance,  are  calculated  to  relieve  the  pain  from  which  the 
patient  suffers,  by  strengthening  the  muscles.  Little  hope,  however,  can 
be  held  out  that  any  amount  of  muscular  exercises  or  stretching  of  the 
spine  will  produce  much  effect  upon  the  curvature.  Theoretically  it  is 
possible  that  prolonged  extension  of  the  spine  might  influence  its  shape, 
but  practically  this  is  almost  impossible. 

The  Scoliosis  of  Adult  Life. — The  condition  met  with  here  is 
precisely  similar  to  that  in  the  group  of  cases  just  described,  except  that 
the  bone  changes  are  perhaps  more  marked  and  are  more  permanent. 
The  treatment  is  identical  with  that  described  above. 

MUSCULAR    EXERCISES.1 

Tt  is  not  intended  that  every  case  shall  perform  all  the  exercises.  The  system  is 
intended  to  present  rather  a  materia  medica  of  exercises,  from  which  the  surgeon  can 
prescribe  those  which  he  considers  best  for  each  case.  The  cases  will  always  have  a 
large  number  of  symmetrical  exercises,  but  the  number  and  kind  of  asymmetrical 
exercises  will  be  prescribed  according  to  the  degree  and  direction  of  the  deformity. 

Generally  the  exercises  should  be  performed  twice  daily  for  a  period  not  usually 
exceeding  half  an  hour.  Children  must  be  made  to  learn  the  exercise  gradually, 
two  or  three  new  ones  being  added  at  each  lesson  as  the  previous  ones  are  learnt 
and  well  done.  The  chief  advantage  of  the  following  system  is,  that  the  essential 
part  of  it  may  be  done  at  home.  Before  practising  the  exercises,  however,  the  patient 
and  one  of  his  relations,  if  the  patient  is  a  child,  should  be  properly  instructed  by 
a  skilled  person — e.g.  a  doctor  or  a  gymnastic  master.  More  rapid  progress  is, 
however,  made  by  having  one  of  the  daily  lessons  performed  at  a  gymnasium,  even 
where  not  more  of  the  apparatus  than  would  be  fitted  up  in  the  patient's  house  is 
used.  The  patient  will  then  be  sure  of  having  at  least  one  lesson  efficiently,  properly, 
and  regularly  performed. 

As  the  strength  improves,  more  rapidity  is  obtained  in  the  improvement  by  the 
use  of  the  new  developing  machines. 

The  gymnasium  is  very  advantageous,  but  the  whole  cure  can  be  done  at  home, 
and  need  not  interfere  with  lessons  or  any  other  business. 

1  These  are  taken  verbatim  from  Dr.  Percy  Lewis's  book  on  The  Relief  and  Cure 
of  Spinal  Curvatures  (London,  1897).  Tne  small  illustrative  figures  are  derived 
from  the  same  source. 


424 


DEFORMITIES 


All  the  exercises  herein  detailed  are  meant  to  be  performed  with  slowness,  ease, 
and  grace,  without  jerking  or  holding  the  breath.  No  exercise  is  to  be  continued 
after  the  first  feeling  of  fatigue  is  induced.  There  should  be  a  rest  between  each, 
the  length  of  which  should  depend  upon  whether  the  exercise  has  been  one  requiring 
little  or  much  expenditure  of  energy.  It  is  advisable  as  far  as  possible  to  interpose 
an  exercise  inducing  little  force  between  two  requiring  more.  In  the  different 
exercises  a  pause  should  intervene  in  moving  from  one  position  to  another,  and 
before  commencing  the  following  exercises  the  patient  must  practise  breathing 
properly.  He  must  inspire  as  freely  and  deeply  as  possible  through  the  nose,  with- 
out strain ;  then,  with  the  mouth  open,  expiration  should  follow  at  once  without 
effort,  being  performed  by  the  elasticity  of  the  chest  and  lungs  alone.  Both  move- 
ments should  be  easily  and  regularly  performed,  and  a  short  rest  should  follow  each 
expiration.  After  each  set  of  three  double  movements  there  should  be  a  longer  rest 
occupied  by  at  least  three  ordinary  breaths. 

N.B. — Most  of  the  exercises  down  to  Series  G  are  taken  from  an  article  by  Madame 
Nageotte-Wilbouchewitch  published  in  the  '  Presse  Medicale  '  of  October  14,  1896. 

HOME    EXERCISES. 

These  exercises  commence  with  very  mild  ones  and  gradually  work  up  to  ones 
requiring  more  strength. 

The  first  are  performed  lying  down  either  prone  or  supine.  The  next  series 
are  made  leaning  against  the  wall  or  other  support.  The  patient  then  performs 
the  same  exercises  standing  without  support.  This  order  is  taken  because  the 
patients  are  mostly  too  feeble  at  first  to  do  exercises  standing  for  more  than  a  few 
minutes,  and  therefore  tend  to  assume  bad  positions.  The  recumbent  position, 
as  before  remarked,  is  a  good  one  for  redressing  the  curves.  In  arranging  the  patient 
perfectly  straight,  some  assistance  may  be  derived  from  the  pattern  of  the  carpet 
or  the  lines  on  the  floor.  The  upright  exercises  should  be  performed  before  a  glass. 

Dollinger,  of  Buda-Pesth,  fixes  black  tapes  across  the  glass,  which  then  act  as 
lines  of  mark.  This  is  a  very  useful  addition,  as  it  enables  patients  to  place  them- 
selves in  a  mesial  position  and  easily  makes  evident  to  them  any  inequality  of  the 
height  of  the  shoulders  or  of  the  sub-axillary  spaces. 

Series  A. — Lying  on  the  Back. 

General  Instructions. — The  patient  lies  down  on  the  floor  or  table,  heels  together 
shoulders  at  the  same  level,  head  straight,  arms  extended  by  the  side  of  the 
body,  palms  facing  upwards.  The  shoulder  blades  are  to  be  pushed  back  so  as 
to  expand  the  chest,  and  the  whole  posterior  surface  of  the  body  should  be  applied 
to  the  surface  of  the  table  so  as  to  efface  the  lumbar  bend  as  much  as  possible. 

Note. — The  efficacy  of  most  of  the  exercises  from  A  to  F  can  be  increased 
by  the  use  of  dumb-bells  from  half  a  pound  to  five  pounds  in  weight. 


I.  Arms  in  three  positions. — (a)  By  the  sides  of  the 
body.  (6)  Straight  out,  forming  a  cross  with  the  body. 
(c)  By  the  side  of  the  head  touching  the  ears,  and  as 
straight  as  possible.  Breathe  while  resting  in  each  atti- 
tude. Return  in  the  same  manner  to  the  position  of  rest 
(see  Fig.  148). 

These  movements  will  exercise  the  pectorals,  all  the 
muscles  attached  to  the  scapula  and  latissimus  dorsi. 


FIG.  148. 


SCOLIOSIS 


425 


2.  Raise  each  leg  to  the  vertical,  knee  kept  straight ; 
return  to  the  position  of  rest,  the  other  leg  immovable. 
Exercise  of  the  psoas  and  iliacus  and  quadriceps 
extensor  (see  Fig.  149). 


FIG.  149. 


3.  Bend  the  head  to  each  side  so  that  the  jaw  rests  on  the  ground  ;  return  slowly 
to  the  position  of  rest  without  moving  the  shoulders.  The  arms  must  be  kept 
immovable,  palms  upwards.  Exercise  of  rotators  and  lateral  flexors  of  head 
and  neck. 


Series  B. 

General  Instructions. — Same,  position  as  above,  except 
that  in  each  case  the  movement  starts  from  the  follow- 
ing position  :  the  elbows  close  to  the  side,  forearm  bent 
upon  the  arm,  fists  closed,  with  the  thumb  side  to  the 
shoulder  (see  Fig.  150). 


FIG.  150. 


i.  (a)  The  length  of  the  body  (see  Fig.  151,0).  (b)  In 
a  cross  (see  Fig.  148,  b).  (c)  Vertically  upwards  (see  Fig. 
151,6).  (d)  By  the  sides  of  the  head  (see  Fig.  148,  c). 

Exercise  of  biceps  and  triceps,  scapular  and  pectoral 
muscles,  and  latissimus  dorsi. 


2.  Move  out  each  leg  transversely,  knee  kept  straight, 
the  other  leg  immovable,  return  to  the  position  of  rest,   s 
Exercise  of  thigh  muscles  and  muscles  passing  from  pelvis 

to  great  trochanters  (see  Fig.  152). 

3.  Bend  the  head  until  the  chin  touches  the  chest ; 
return  slowly  to  the  position  of  rest  (see  Fig.  153).     Exer- 
cise of  sterno-mastoid,  anterior  neck  muscles,  and  splenius, 
complexus  and  posterior  neck  muscles. 


FIG.  153. 


Series  C. 

1.  Circular  turn  of  the  arms. — The  palms  upwards,  the 
arms  describe  a  half  circle  on  the  earth,  to  rejoin  at  the 
sides  of  the  head  (see  Fig.  148,  c).     There  the  fingers  cross 
each  other  (see  Fig.  154),  the  patient  stretches  out  as  far  _=-,< 
as  possible,  and  brings  the  arms  back  parallel  to  the  side 

of  the  body  by  describing  a  half  circle  in  a  vertical  plane 
(see  Fig.  151,6).  Exercise  of  all  the  muscles  attached  to  the 
scapula  and  upper  end  of  the  humerus. 

2.  Circular  movement  of  the  leg.— The  leg  held  straight  is  lifted  vertically,  carried 
outwards  to  the   earth,   and   returned  to  its  place.     All    the  rest   of  the  body 


FIG.  ij4. 


426 


DEFORMITIES 


immovable.      Exercise  of  psoas  and  iliacus,   and   all    the   muscles  of  the  thigh, 
including  those  passing  from  the  pelvis  to  the  femur,  and  sartorius  (see  Fig.  149). 

3.  Circular  movement  of  the  head. — The  head  is  first 
bent  forwards  until  the  chin  touches  the  chest  (see  Fig. 
153),  then  the  head  is  inclined  in  such  a  manner  that  the 
ear  touches   the  shoulder  (see  Fig.  155)  ;    return   to  the 
FIG.  155.  position  of  rest  in  the  same  level.     Repeat,  inclining  the 

head  to  the  opposite  side.     Exercise  of  the  muscles  on 
each  side  of  the  neck. 


Series  D. 

i.  Sit  up  without  the  aid  of  the  arms,  the  back  straight,  the  head  stretched 
out  (see  Fig.  156,0).    Lie  down  again  very  slowly  without  bending  the  back.    Exercise 
of  the  psoas  and  iliacus  and  of  anterior  abdominal  muscles 
chiefly. 

2.  Lift  the  legs  stretched  very  slowly  as  far  as   the 
vertical.      Lower  them  slowly.      Exercise   of  psoas  and 
iliacus  and  anterior  thigh  muscles  (see  Fig.  149). 

3.  Place  the  right  hand  on  the  ribs  as  high  up  and  as 
far  back  as  possible,  thumb  forwards.     Place  the  left  fore- 
arm on  the  head  so  that  the  left  fingers  touch  the  right 
ear.     Bend  all  the  body  above  the  right  hand  as  far  as 
possible  to  the  right  (see  Fig.  156,6).     Take  a  few  deep 
inspirations    and    return  to    the    symmetrical    position. 
Exercise  for  right  dorsal  curve. 

4.  Repeat  the  preceding  exercise  in  a  reverse  manner. 
Exercise  for  left  dorsal  curve. 

5.  Arms    in    a    cross.      Legs    and    hips  immovable, 
head    straight.     Bend  the  whole  body  to  the  left   (see 

Fig.  156,  c).      Remain  during  a  few  inspirations.     Return  to  the  position  of  rest. 
Exercise  for  right  lumbar  curve. 

6.  Repeat  in  the  opposite  direction.     Exercise  for  left  lumbar  curve. 


FIG.  156. 


Series  E.— Lying  on  the  Stomach. 


i .  Arms  strongly  stretched  at  the  sides,  raise  oneself, 
breathe.     Exercise  for  erector  spinae  (see  Fig.  157). 


FIG.  157. 


2.  Lift  each  leg  stretched.     Perform  circular  move- 
ment.    The  head  rests  on  the  jaw  of  the  side  of  the  limb 
lifted   (see  Fig.  158).     Exercise  of  thigh  muscles,    glutei 
E^*r-_:  extensors,  and  rotators. 


FIG.  158. 


SCOLIOSIS 


427 


Swimming  Movement. 


3.  The  palms  face  the  ground  during  the  whole  exer- 
cise, contrary  to  the  attitude  of  real  swimming.  The 
shoulder  blades  are  not  to  move  on  the  chest.  The  elbows 
and  hands  are  not  to  touch  the  ground  so  as  to  avoid  pas- 
sive supporting  (see  Fig.  159).  To  rest,  the  patient  lies 
down  completely.  Exercise  for  erector  spinae,  latissimus 
dorsi,  scapular  and  pectoral  muscles. 


Series  F.— Exercises,  done  in  the  Upright  Position  with  Support. 

General  Instructions. — The  patient  either  simply  leans  against  the  wall,  or  at 
first  is  held  there  by  a  strap  round  the  waist  until  he  can  hold  himself  upright 
without  support.  More  muscles — viz.  those  required  to  maintain  the  erect  posture 
— will  be  brought  into  play,  and  the  exercise  will  thus  be  more  severe. 

i.  The  first  three  series  of  movements — viz.  A,  B,  and  C — are  then  done  in  this 
position  (see  Figs.  160-2). 


FIG.  160. 


FIG.  161.  Fio.  l6a. 


2.  Then  D  3,  4,  and  5  (see  Fig.  163 ).  No.  5  may,  however,  be  carried  still 
further  in  this  position— viz.  until  the  fingers  touch  the  ground,  (a)  By  placing 
the  legs  apart  and  bending  the  left  knee,  or  (b)  By  allowing  the  right  foot  to 
leave  the  ground  so  that  the  body  see-saws  on  the  left  hip  joint  (see  Fig.  164). 


FIG.  163. 


FIG.  164. 


428  DEFORMITIES 


Series  G. — Movements  made  without  Support. 

All  the  movements  which  have  been  done   against  the  wall    should  at  last  be 
performed  without  such  help  ;   also 


i.  Breathing. — Hands  clasped  behind  the  waist,  in- 
spire; hands  still  clasped  but  arms  forcibly  stretched 
downwards,  expire  (see  Fig.  165). 


FIG.  165.  2.  Flexion  of  trunk. — Head  straight,  arms  extended 

at  sides  of  the  head,  bend  the  trunk  forwards  at  the  hips, 
so  that  the  fingers,  united  by  their  palmar  surfaces,  touch 
the  ground  ;  return  to  the  previous  attitude  with  the 
arms  in  the  same  position.  The  legs  to  remain  very 
straight,  the  feet  a  little  apart  (see  Fig.  166).  The  repe- 
titions of  the  movement  to  be  separated  by  circular 
movements  of  the  arms.  Exercise  of  anterior  abdominal, 

FIG.  166.  erector  spins,  glutei,  psoas,  and  thigh  muscles. 

3.  Sit  down  slowly  upon  'the  heels  with  the  arms  extended  horizontally  in 
front ;  recover  to  the  standing  position  while  letting  the  arms  fall.     Exercise  of 
thigh,  glutei,  and  erector  spinae  muscles. 

4.  Bend  the  trunk  forwards,  backwards,  laterally,  and   lastly  circularly,  the 
hands  resting  upon  the  hips.     Exercise  of  anterior,  posterior,  and  lateral  abdominal 
muscles,  and  erector  spinae. 

5.  Separate  the  arms  horizontally  backwards  as  far  as  possible  with  inspiration  ; 
bring   them  together    in  front  with  expiration.     Exercise  of  pectorals,   scapular 
muscles,  and  latissimus  dorsi. 

6.  The  untwisting  exercise. — Patient  standing,  the  arms  straight  and  horizontal, 
and  inclined  as  far  as  possible  to  the  right,  are  rapidly  moved  across  the  body  as 
far  as  possible  to  the  left ;    the  whole  spine  at  the  same  time  rotating  to  the  left. 
Thus  the  hands  describe  about   three-quarters    of  a  circle   in  a  horizontal  plane. 
Maintain  this  position  for  a  few  moments,  then  allow  the  arms  to  fall  and  the  spine 
to  come  into  a  position  of  rest.     Exercise  for  rotation  to  the  right. 

This  is  one  of  the  most  important  and  powerful  of  the  asymmetrical  movements. 
Its  power  is  much  increased  by  using  the  Dowd's  machine  (see  Fig.  146). 

7.  Reverse  the  exercise.     Exercise  for  rotation  to  the  left. 

8.  For  poking  of  the  chin. — Patient  sitting.     Slowly  bend  head  forwards  until 
chin  touches  chest,  then  rapidly  bend  backwards  as  far  as  possible.     Maintain  the 
position  a  few  seconds ;    return  slowly  to  position  of  rest.     Exercise  of  complexus, 
trapezius,  splenius,  etc. 

9.  Patient  sitting ;    arms  by  side,  simultaneously  draws  back  both  shoulders 
as  far  as  possible,  keeps  them  in  this  position  whilst  he  counts  four,  and  then  allows 
them  to  return  to  original  position.     Exercise  of  scapular  and  latissimus  muscles. 

10.  Patient  sitting ;    bends  the  body  on  to  the  thighs,  then  slowly  rises  again. 
Exercise  of  anterior  abdominal,  psoas  and  iliacus,  and  erector  spinae  muscles. 

11.  Patient  standing  opposite  a  wall  and  an  arm's  length  from  it,  stretches  out 
the  arms  horizontally  in  front,  and  applies  the  hands  flat  against  the  wall  ;    with- 
out moving  his  feet  the  patient  slowly  approaches  his  body  to  the  wall  by  bending 
the  arm  on  the  forearm  ;   then  he  slowly  recovers. 


429 


arm 


SCOLIOSIS 

This  passively  expands  the  chest  and  causes  contraction  of  the  shoulder  and 
muscles  on  both  sides. 

Note.— All  the  preceding  exercises  are  at  first  made  by  the  patient  alone.  By 
interposing  resistance  to  the  muscular  effort  the  efficacy  of  the  various  movements 
can  be  increased  at  the  will  of  the  surgeon  as  the  patient  increases  in  strength. 

12.  The  patient  is  seated  in  a  chair  with  a  straight 
back,  reaching  as  high  as  the  shoulders,  a  band  fixing 
the  trunk  to  the  back.  The  patient's  back  and  shoulders 
should  be  firmly  applied  to  the  back  of  the  chair.  A 
rod  or  stick  about  four  feet  long  is  then  grasped  firmly 
by  the  hands,  about  two  inches  or  more  from  the  ends, 
and  raised  above  the  head,  the  hands  still  remaining  the 
same  distance  from  the  ends.  The  rod  is  next  lowered 
behind  the  back  of  the  chair  as  far  as  possible.  The 
hands  must  still  retain  their  position  on  the  rod,  but  the 
elbows  must  be  bent.  Alternately  raise  and  lower  (see 
Fig.  167). 

Note. — As  the  patient  gets  stronger  the  band  will  be  unnecessary. 

This  is  also  a  chest-expanding  exercise,  calling  into  action  the  muscles  on  front 
and  back  of  the  chest. 


FIG.  167. 


Series  I.— Exercises  over  the  Edge  of  a  Table. 

i.  Lying  down  flat  on  the  stomach  on  the  table.  The 
legs  fixed  by  a  strap  across  the  ankles,  the  trunk  going 
beyond  the  table  as  far  as  the  hips.  The  arms  stretched 
behind  the  back,  bend  the  trunk  down  as  far  as  the  verti- 
cal, raise  the  head  first,  then  recover  slowly,  stretching  the 
arms  forcibly  and  breathing  deeply  to  the  maximum  of 
recovery  (see  Fig.  168).  Repeat  three  times  in  succession. 
Rest,  then  repeat  six  times  slowly.  To  rest,  rise  on  to  the 
knees  on  the  table. 

N.B. — If  the  curvature  is   bad,  extension   must  be  limited   to  rising  to   the 
horizontal  line. 

Exercise  chiefly  of  the  erector  spinae  and  its  continuations. 


Fie.  168. 


2.  Sit  at  the  edge  of  a  table  with  back  at  edge,  and 
feet  retained  by  a  strap,  then  head  and  back  straight 
and  arms  stretched  behind  the  back,  slowly  lie  down, 
breathe,  return  to  the  first  position  (see  Fig.  169). 

Note. — Until  strong  enough  the  patient  must  be  sup- 
ported through  this  exercise.  The  back  must  be  kept 
straight,  not  rounded. 

This  is  an  exercise  chiefly  of  the  anterior  abdominal, 
psoas,  and  iliacus,  and  front  of  thigh  muscles. 


430 


DEFORMITIES 


FIG.  170. 


3.  Same  exercise  lying  on  the  side  ;  the  concavity  of 
the  principal  curve  downwards  (see  Fig.  170).  It  is  an 
exercise  of  over-correction,  which  is  very  difficult  to 
perform  and  also  to  teach. 


Series  J.—  With  Dowd's  Machine. 


e.  —  In  using  Dowd's  machine,  the  patient  is  to  commence  without  any  other 
weight  than  that  of  the  weight-carrier.  Gradually  weights  are  added  as  the  doctor 
may  direct.  It  may,  for  various  reasons,  be  found  necessary  to  add  more  weights 
to  one  side  than  to  the  other.  For  instance,  in  the  face-to-machine  exercises  for  a 
patient  with  rotation  to  the  right,  it  would  be  well  to  place  more  weights  on  the  right 
side  than  the  left.  In  the  back-to-machine  exercises  greater  weight  on  the  left 
would  then  tend  to  untwist. 

1.  Patient  facing  machine.  —  Patient  stands  facing  machine.     Right  hand  straight 
out  in  front,  grasping  handle  of  machine,  is  made  to  describe  a  circle  in  a  horizontal 
plane,  being  carried  as  far  back  as  possible.     Return  to  original  position. 

2.  Ditto,  left  hand. 


/  t 


3.  Same  exercise,  both  hands  together  (see  Fig.  171, 
which  shows  the  exercise,  but  with  the  patient  back  to 
machine,  vide  Series  K,  3). 


FIG.  171. 


4.  Right  hand  held  vertically  up,  grasping  handle  of  machine,  is  brought  down 
in  front,  describing  a  semicircle  in  a  vertical  plane. 

5.  Ditto,  left  hand. 


6.  Ditto,  both  hands  at  same  time  (see  Fig.  172,  which 
is  also  back  to  machine,  vide  Series  K  6). 


FIG.  172. 


7.  Right  hand  held  vertically  up  and  straight,  grasping  handle  of  machine,  is 
brought  down  at  the  side  describing  a  semicircle  in  a  vertical  plane.     Return  to 
original  position. 

8.  Left  hand,  ditto. 


SCOLIOSIS 


43i 


9.  Ditto,  both  hands  at  same  time  (see  Fig.  173). 


FIG.  173. 


10.  Elbows  bent  and  at  sides  of  body,  both  hands 
grasping  handles,  arms  to  be  alternately  straightened  and 
returned  to  original  position  (see  Fig.  174). 


FIG.  174. 


ii.  Arms  straight  out  in  front,  hands  grasping  handles,  bend  elbows  and  bring 
them  back  until  they  come  to  sides  of  the  body  ;  hands  remain  straight  out.  Alter- 
nately repeat  and  return  to  original  position. 


12.  Incline  head  towards 
machine,  grasp  one  handle 
with  both  hands  and  hold  it 
in  contact  with  back  of  the 
head.  Bend  head  as  far 
back  as  possible  from  the 
neck,  carrying  handle  and 
hands  with  it.  Alternately 
repeat  and  return  to  original 
position  (see  Fig.  175). 


FIG.  175. 


Fi<s.  176. 

13.  Same  exercise,  but  bending  back  and  neck  as  far  back  as  possible  (see 
Fig.  176). 


432 


DEFORMITIES 


14.  Patient  erect,  holding  handle  and  hands  in  same 
position  ;  bend  forwards,  bringing  head  as  low  as  possible. 
Return  to  original  position  (see  Fig.  177). 


FIG.  177. 

15.  Right  arm  straight  out  from  side,  hand  grasping  handle.     Hand  describes 
a  circle  about  a  foot  in  diameter,  its  first  position  being  the  centre. 

1 6.  Ditto,  left  arm. 

17.  Ditto,  both  arms  at  same  time. 


1 8.  The    untwisting    exercise, 
Series   G,   6    (see   Fig.  178). 


FIG.  178. 

19.  Ditto,  Series  G,  7. 

20.  Right  arm  straight  out  in  front,  the  hand  grasping  handle  is  carried  vertically 
upwards,  then  outwards,  downwards  as  far  as  possible,  and  finally  returns  to  original 
position  after  describing  a  circle. 

21.  Left  arm  ditto. 

22.  Both  arms  together  ditto. 

Series  K.— Patient  with  Back  to  Machine. 


i.  Series  J,  Number  i,  reversed. 


2.          „         „ 

2, 

, 

3-        »       » 

3, 

JJ 

4-        »       y> 

»         4. 

>] 

5-        ,.        .» 

5, 

i; 

6-        „       „ 

6, 

?! 

7-        »       » 

7, 

M 

3.        „       „ 

8, 

)) 

9, 


(See  Fig.   171.) 


(See  Fig.  172.) 


(See  Fig.  173.) 


10.  Series  J,  Number  14,  reversed  (see  Fig.  179). 


FIG.  179. 


SCOLIOSIS 
ii.  Series  J,  Number  16,  reversed. 


433 


M- 
I5- 

ID- 


20, 

21, 

22, 


Series  L.— Side  to  Machine  Exercises. 

1 .  Right  side  to  machine ;   arm  straight  out  grasping  handle  is  carried  upwards 
to  side  of  head  ;    returns  to  first  position,  pauses,  and  is  brought  down  to  side ; 
reverse ;    repeat. 

2.  Left  side  to  machine  ;   same  exercise  for  left  arm. 


3.  Right  side  to  machine ; 
left  forearm  resting  on  head,  left 
hand  over  right  ear  grasping 
handle  (see  Fig.  180).  Patient 
leans  as  far  as  possible  to- 
wards machine,  recovers  and 
leans  as  far  as  possible  away 
from  it ;  hips  and  legs  immov- 
able (see  Fig.  181). 


FIG.  1 80. 


FIG.  181. 


4.  Repeat  with  left  side  to  machine,  right  arm  over  head. 

5.  Repeat  3,  with  a  circular  instead  of  a  to-and-fro  movement. 

6.  Repeat  4,  with  a  circular  instead  of  a  to-and-fro  movement. 

Note. — It  will  be  seen  that  most  of  the  exercises  with  Dowd's  machine  are  chiefly 
the  previous  exercises  performed  with  apparatus.  The  machine  simply  is  an 
accurate  means  of  adding  increasing  resistance  by  putting  more  weights  on  to  the 
carrier.  The  same  remarks  apply  more  or  less  to  all  the  developing  machines  here- 
after mentioned. 

Series  M. — Exercises  with  a  Single  Dowd's  Machine,  the  Rope  passing 
under  a  Pulley  attached  to  the  Floor.    (Face  to  Machine.) 


1.  Right  arm  obliquely  in  front  holding  handle, 
of  head  without  bending  arm. 

2.  Left  arm  ditto. 


Raise  to  the  vertical  by  side 


3.  Both  grasping  handle  at  same  time  (se«  Fig.  182). 


FIG.  182. 

4.  Right  arm  obliquely  in  front,  raise  forearm  as  far  as  possible  without  moving 
upper  arm. 

5.  Left  arm  ditto. 

FF 


434 


DEFORMITIES 


6.  Both  together  ditto  (see  Fig.  183). 


FIG.  183. 


7.  Right  arm  obliquely  in  front,  grasping  handle,  is  carried  backwards  as  far  as 
possible,  and  allowed  to  return  to  original  position. 

8.  Left  arm  ditto. 


9.  Both  together  ditto  (see  Fig.  184). 


FIG.  184. 


10.  Arms  straight  out  in  front,  both  hands  grasping 
handle,  body  bent  forwards  as  far  as  possible,  is  raised 
and  carried  backwards  as  far  as  possible,  arms  remain 
straight  (see  Fig.  185). 


FIG.  185. 


Series  N. — With  Single  Dowd  as  for  Series  M,  but  instead  of  a  Handle 
the  Rope  is  fixed  to  a  Strap  which  is  fastened  to  each  foot  in 
turn.  (For  Right  Foot.) 


i.  Facing  machine,  right  hand  resting  on  back  of  a 
chair,  leg  straight  is  alternately  carried  forwards  and 
backwards  (see  Fig.  186). 


2.  Similar  exercise  with  back  to  machine. 


FIG.  186. 


3.  Facing  machine,  right  hand  resting  on  back  of 
chair,  leg  is  brought  from  being  in  a  line  with  left  as  high 
up  as  possible  by  bending  the  knee.  Thigh  remains 
immovable  (see  Fig.  187). 


FIG.  187. 


SCOLIOSIS 


435 


4.  Left  side  towards  machine,  left  hand  on  back  of 
chair,  the  left  leg  is  alternately  in  front  of  right  as  far  as 
possible  to  right,  and  returned  to  original  position  (see 
Fig.  1 88). 


5.  Left  side  towards  machine,  the  right  hand  on  back 
of  a  chair,  the  right  leg  is  carried  from  contact  with  the 
left  as  far  out  as  possible  (see  Fig.  189). 


Fie.  188. 


FIG.  189. 


6.  Left  side  to  machine,  right  hand  on  back  of  a 
chair,  left  leg  held  obliquely  outwards  towards  the 
machine,  thigh  immovable,  the  left  knee  is  bent  until  the 
foot  touches  the  right  leg  (see  Fig.  190). 


FIG.  190. 


7.  Patient  seated  right  side  to  the  machine,  the  left  foot  is  alternately  turned 
outwards  and  allowed  to  recover. 


FIG.  191. 


8.  Reverse  exercise  by  turning  left  side  to  machine 
(see  Fig.  191). 


9.  Same  as  r,  reversed. 


10. 
ii. 
12. 

13- 
14. 

15- 
16. 


,,  2, 

„  3, 

,.  4, 

„  5, 

„  6, 

»  7, 

„  8, 


F  F  2 


DEFORMITIES 


Exercises  fop  the  Medical  Gymnasium. 


Note. — Any  of  the  exercises  for  Dowd's  machine  may 
be  performed  with  any  of  the  modifications  of  it.  Thus 
the  high  Dowd's  (see  Fig.  192)  may  be  used  in  the  same 
way,  where  it  is  required  to  develop  especially  the  lower 
part  of  the  chest,  to  help  the  latissimus  dorsi  and  the 
lower  part  of  the  serratus  magnus,  trapezius,  pectorals, 
etc.,  in  their  elevating  action  on  the  lower  ribs. 


FIG.  192. 


The  Quarter-circle  Dovid  (see 
Fig.  193)  will  be  especially  useful 
in  stooping  and  posterior  curves  of 
the  spine. 


FIG.  193. 


SCOLIOSIS 


437 


The  rowing  machine  (see 
Fig.  194)  is  a  very  powerful 
combination  of  all  the  Dowds, 
only  to  be  used  towards  the  end 
of  the  course.  It  exercises  prac- 
tically all  the  muscles  of  the 
body. 


Fio.  194. 


Series  0.— Wheel  Exercise. 

i.  Patient  standing  with  back  to  wheel,  arms  out  in  a  cross  grasping  the  pro- 
jecting pegs.  See-saw  action,  to  and  fro  (see  Fig.  195).  Increase  resistance  accord- 
ing to  the  patient's  strength. 


FIG.  195. 

2.  Right  side  to  machine,  left  hand  on  left  hip,  right  hand  grasping  peg  at 
summit  of  circle,  right  foot  forwards,  spine  stiff.     Right  hand  turns  wheel  from 
above  downwards. 

3.  Same,  left  foot  forward. 

4.  Same  as  2,  reversed. 

5.  Same  as  3,  reversed. 

6.  Right  side  to  machine,  feet  together,  right  hand  grasping  lowest  peg,  left 
hand  passing  over  head  grasps  highest  peg,  right  hand  to  move  forwards,  left  hand 
backwards. 

7.  Same,  reversed. 


DEFORMITIES 


EXTENSION   EXERCISES   FOR  ACTING   CHIEFLY   ON    THE 
SPINAL   LIGAMENTS. 

Series  P. — Oblique  Ladder. 

1.  Patient  on  back,  feet  on  lowest  two  rungs,  hands  on  highest  rungs  he  can 
reach.     Raise  feet  to  the  rungs  of  next  level,  the  hands  bearing  the  weight  mean- 
while.    Remove  the  feet  from  the  rungs  for  a  few  seconds  so  that  hands  bear  all 
the  weight.     Raise  feet  to  next  level,  and  so  on  until  the  top  is  reached.     Come 
down  in  reverse  order. 

2.  Ditto,  with  right  arm  always  one  rung  above  the  left. 

3.  Ditto,  with  left  arm  always  one  rung  above  the  right. 


Series  Q. — Exercises  with  Parallel  Rings. 


i.  Patient  stands  between 
rings,  which  are  suspended 
about  a  foot  above  his  head, 
and,  keeping  feet  fixed  as  a 
pivot,  performs  a  circular 
movement  of  the  whole  body, 
from  right  forwards  to  left ; 
from  left  backwards  to  right 
(see  Fig.  196). 


FIG.  196. 

2.  The  rings  may  be  gradually  lowered. 

3.  Right  ring  may  be  a  few  inches  higher  than  the  left. 

4.  Left  ring  may  be  a  few  inches  higher  than  the  right. 


Series  R.— Vertical  Pole  or  Rope. 

Note. — This  exercise  is  best  performed  with  the  pole  or  rope  rigid  or  suspended 
against  a  wall. 

1.  Patient  standing  with  back  to  pole,  the  hands  above  head,  grasps  the  pole 
as  high  as  possible  ;  then,  raising  the  heels  from  the  ground,  the  patient  endeavours, 
with  one  hand  at  a  time,  to  grasp  the  pole  just  above  the  other  hand.     The  patient 
then  allows  the  hands  to  bear  the  weight  in  endeavouring  to  get  the  heels  again 
on  to  the  ground. 

2.  Same  exercise,  right  hand  always  higher. 

3.  Same  exercise,  left  hand  always  higher. 


SCOLIOSIS  439 

Series  S.— Trapeze. 

i.  Patient  standing  on  a  stool,  trapeze  at  such  a  height  that  the  patient  can 
just  reach  it  with  hands  above  head.  Patient  grasps  trapeze,  stool  is  removed, 
and  patient  swings  backwards  and  forwards  by  alternately  flexing  and  extending 

his  legs. 

Series  T.— Vertical  Ladder  or  Gridiron. 

1.  Same  as  Series  P,  i. 

2.  Same  as  Series  P,  2. 

7 

3.  Same  as  Series  P,  3. 

4.  Right  foot  on  one  of  the  lower  rungs,  right  hand  on  one  of  the  upper,  so  that 
the  right  side  of  the  body  forms  a  concavity  towards  the  ladder.     Alternately 
stretch  left  arm  and  left  leg  as  far  to  the  left  as  possible,  and  allow  them  to  return 
to  the  hanging  position. 

5.  Ditto,  reversed. 

6.  Climb  with  back  to  ladder  using  only  left  hand,  right  carrying  a  weight. 

7.  Same,  with  face  to  ladder. 

8.  Same  as  6,  left  hand  carrying  a  weight. 

9.  Same  as  7,  left  hand  carrying  a  weight. 

Series  V.— Dumb-bells. 

1.  Holding  dumb-bell  of  five  pounds  or  more  at  level  of  shoulder  in  right  hand. 
Alternately  raise  and  lower. 

2.  Ditto,  with  left  hand. 

Series  W. 

i.  Alternately  raise  above  head  and  lower  a  heavy  steel  bar,  using  both  hands. 
The  patient  should  fix  his  eyes  on  the  centre  of  the  bar. 


APPENDIX 


ANAESTHETICS 

BY 

DR.  J.  F.  W.  SILK 

Anaesthetist  to  King's  College  Hospital 


THE    EXAMINATION    OF   THE    BLOOD 
IN    SURGICAL  CONDITIONS 


DR.  W.  D'ESTE  EMERY 

Lecturer  on  Pathology,  King's  College  Hospital 


ANESTHETICS. 

BY  DR.  J.  F.  W.  SILK. 

THE  abolition  of  pain,  quietness,  muscular  relaxation,  and  the  diminution 
of  shock  are  the  chief  objects  we  have  in  view  in  placing  a  patient  under 
an  anaesthetic.  To  attain  these  ends,  no  method  is  so  certain  and  so 
universally  applicable,  as  that  of  general  anesthesia  by  inhalation,  the 
patient  being  rendered  unconscious.  It  may  sometimes  be  undesirable 
to  subject  the  patient  to  the  comparatively  slight  dangers  and  discom- 
forts of  a  general  anaesthetic,  but  to  limit  the  anaesthesia  to  the 
area  to  be  operated  upon.  In  such  cases  local  anesthesia  may  be 
employed. 

PART  I. 
GENERAL   ANAESTHESIA. 

PRELIMINARY  OBSERVATIONS. 

Preparation  of  the  Patient. — With  the  possible  exception  of  nitrous 
oxide  (see  p.  448),  an  anaesthetic  is  always  taken  better  if  the  patient 
has  been  subjected,  for  a  few  days,  to  what  may  be  termed  hospital 
regime.  This  does  not  of  necessity  mean  absolute  confinement  to  bed, 
but  it  implies  rest  of  body  and  mind,  careful  regulation  of  the  ordinary 
bodily  functions,  light  and  easily  digested  diet,  and  abstention  from 
alcohol.  Young  children  and  highly  neurotic  adults  are  often  best  kept 
in  ignorance  of  an  impending  operation,  but  such  patients  frequently  give 
trouble  under  an  anaesthetic,  and  so  confirm  the  value  of  the  general 
rule. 

It  has  been  suggested  that  a  course  of  some  such  drug,  as  strychnine, 
quinine,  iron,  etc.,  should  be  given  for  a  few  days  before  the  operation, 
with  a  view  to  obviating  some  of  the  difficulties  and  dangers  which  may 
arise  during  the  administration  of  an  anaesthetic.  The  tonic  properties 

443 


444  ANESTHETICS 

of  such  substances  are,  no  doubt,  of  value,  but  it  has  not  yet  been  proved 
that  any  of  them  possess  a  specific  action  in  the  matter. 

A  purge,  in  the  shape  of  castor  oil,  compound  liquorice  powder, 
calomel,  colocynth,  or  compound  rhubarb  pill,  is  usually  given  the  night 
before  the  operation,  and,  if  necessary,  an  enema  in  the  morning ;  this 
may  consist  either  of  plain  water  or  soap  and  water.  The  latter  is  made 
by  rubbing  up  Castile  soap  in  warm  water  until  a  thick  lather  is  formed, 
and  about  a  pint  is  injected. 

Diet. — It  is  important  that  the  stomach  should  be  empty  before  the 
inhalation  commences  ;  but  starvation  may  be  carried  too  far,  especially 
in  the  feeble.  Each  case  should  be  treated  upon  its  merits,  according 
to  the  digestive  capacities  and  general  health  of  the  individual,  and  bear- 
ing in  mind  that  the  mere  dread  of  the  operation  will  often  retard  the 
digestion  for  hours.  The  best  time  for  operating1  is  the  early  morning, 
in  which  case  no  food  need  be  given  after  supper  on  the  previous  evening. 
If  the  operation  be  fixed  for  the  afternoon  (at  or  after  i  P.M.),  a  light 
breakfast  should  be  taken  not  later  than  8  A.M.,  and  a  cup  of  hot  broth 
or  beef  tea,  or  even  hot  water  alone,  should  be  given  not  less  than  three 
hours  before  the  actual  time  of  operation  ;  this  is  useful  in  counteracting 
the  feeling  of  exhaustion  and  faintness,  of  which  many  persons  complain 
if  kept  fasting  too  long.  Milk  and  other  slowly  digestible  substances 
should  be  avoided. 

In  cases  of  special  gravity,  either  from  the  condition  of  the  patient 
or  the  probable  severity  of  the  operation,  it  will  be  found  useful  to  give, 
when  possible,  a  nutrient  enema  (yolk  of  one  egg,  one  ounce  each  of 
beef-tea,  milk,  and  brandy,  peptonised.i  if  the  patient  be  particularly 
exhausted)  half  an  hour  before  he  is  placed  upon  the  table,  care  being 
taken  to  wash  out  the  rectum  with  warm  water  before  the  enema  is 
injected. 

Alcohol. — Physiologically  or  clinically  considered,  the  use  of  brandy 
by  the  mouth  is  irrational,  as  it  encourages  the  tendency  to  retching 
and  vomiting,  and  increases  the  poisonous  effects  of  the  anaesthetics. 
It  may  become  necessary,  however,  in  cases  of  impending  syncope,  and 
in  some  few  instances  its  administration  may  have  a  good  moral  effect, 
but,  as  a  general  rule,  it  is  not  desirable. 

Hypodermic  medication,  immediately  before  the  inhalation,  has  been 
advocated,  the  drugs  most  frequently  employed  being  morphine,  atropine, 
scopolamine,  strychnine,  and  digitaline.  Morphine  (^  to  £  grain)  is  said  to 
diminish  shock,  and  to  make  it  possible  to  keep  the  patient  anaesthetised 
with  a  weaker  vapour  than  might  otherwise  be  necessary  ;  it  is  claimed 

1  To  peptonise,  add  15  gr.  bicarbonate  of  soda  and  a  dessertspoonful  of  Benger's 
Liquor  Pancreaticus  or  5  gr.  of  Fairchild's  Zymine.  Place  the  jar  containing  the 
mixture  in  a  basin  of  water  as  hot  as  the  hand  can  bear.  Allow  it  to  remain  for  half 
an  hour,  then  heat  it  quickly  to  boiling  point  for  one  minute.  Cool  for  injecting. 


PRELIMINARY  OBSERVATIONS  445 

for  atropine  (T^n  grain  with  or  without  morphine)  that  it  prevents 
cardiac  inhibition,  and,  by  checking  the  flow  of  saliva  and  mucus,  averts 
after-sickness.  Scopolamine  (^  grain)  is  used,  alone  or  with  morphine 
(^  grain),  to  produce  a  state  of  stupor  or  semi-narcosis  which,  it  is  said, 
renders  the  use  of  an  anaesthetic  vapour  nearly  superfluous;  a  dose 
of  the  combined  drugs  is  given  on  the  previous  evening,  and  this  is  re- 
peated on  the  morning  of  the  operation.  Digitaline  may  be  given  as  a 
cardiac  tonic  when  required  (T-^  grain) .  In  my  experience  the  advantages 
of  these  drugs  is  rather  more  theoretical  than  practical,  and  the  use  of 
them  as  a  matter  of  routine  is  open  to  the  objection  that  they  tend  to 
mask  the  ordinary  symptoms  of  over-narcosis.  There  seems  to  be  some 
reason  for  believing  that  strychnine  is  of  considerable  value  in  obviating 
or  diminishing  what  may  be  termed  '  operation  shock,'  1  and  it  is  also 
claimed  by  some  that  the  tendency  to  sickness  is  lessened  by  its  use. 
In  the  feeble,  therefore,  and  in  severe  operations,  ^  grain  may  be  in- 
jected, either  immediately  before  or  immediately  after  anaesthesia  is 
induced,  and  the  dose  may  be  repeated  once  or  twice  during  the 
course  of  the  operation  ;  this  does  no  harm,  and  may  do  a  great  deal 
of  good. 

Before  the  inhalation  is  commenced,  every  care  must  be  taken  to 
remove  anything  that  may  interfere  in  the  slightest  degree  with  the  most 
absolute  respiratory  freedom ;  even  in  normal  sleep  the  least  pressure 
on  the  chest  may  cause  an  immense  amount  of  discomfort.  Plugs  of 
tobacco,  artificial  teeth,  obturators,  etc.,  should  be  removed,  lest  they 
fall  or  get  pushed  into  the  larynx  or  pharynx  ;  collars,  stays,  belts, 
waistbands,  braces,  or  bandages,  must  be  completely  relaxed. 

In  some  instances,  auscultation  of  the  chest  and  heart  increases  the 
trepidation  of  the  patient,  and,  in  by  far  the  majority  of  cases,  the  infor- 
mation obtained  is  valueless  or  misleading.  On  account  of  nervousness 
the  rate  and  rhythm  of  both  cardiac  and  breath  sounds  are  much  inter- 
fered with,  and  the  accurate  detection  of  slight  lesions  becomes  almost 
impossible.  Although  auscultation  is  not  to  be  recommended  as  a 
routine  practice,  the  anaesthetist  is  bound,  nevertheless,  to  acquaint 
himself,  through  the  medical  attendant,  or  through  the  patient  and  his 
friends,  with  all  points  in  the  medical  history  of  the  case  which  may  have 
any  bearing  upon  the  question  of  the  anaesthetic,  especially  in  connection 
with  the  respiratory  and  circulatory  systems  ;  in  cases  of  doubt,  or  if 
the  slightest  desire  for  it  be  manifested  by  the  patient  or  his  friends,  a 
careful  examination  should,  of  course,  be  undertaken.  It  will  probably 
help  to  calm  the  patient  if  the  pulse  be  felt,  although,  for  the  reasons 
indicated  above,  but  little  real  information  is  gained,  beyond  detecting 
any  marked  thickening  or  atheroma  of  the  arterial  walls. 

1  Prof.  Wood  of  Philadelphia,  Transactions  of  the  International  Medical  Congress, 
Berlin,  1890,  vol.  i.  p.  133. 


446  ANAESTHETICS 

The  position  of  the  patient  on  commencing  the  inhalation  must 
vary  slightly  under  different  circumstances.  Fussy  attempts  to  '  arrange ' 
the  patient  are  to  be  deprecated,  and,  generally  speaking,  the  best  rule 
to  adopt  is,  to  allow  the  patient  to  assume  the  recumbent  posture  most 
convenient  and  comfortable  to  himself.  In  most  instances  this  will  be 
supine,  when,  especially  if  there  be  any  tendency  to  emphysema,  the 
head  and  shoulders  should  be  well  supported  with  pillows.  With  the 
patient  sitting  up  (nitrous  oxide  or  ether),  care  must  be  taken  that  the 
head  is  placed  in  such  a  position  that  the  tongue  does  not  fall  back  over 
the  glottis.  In  some  few  cases,  the  patient  naturally  assumes  the  lateral 
position,  and  in  this  the  anaesthetist  should  acquiesce.  The  great  object 
in  view  is,  to  make  the  necessarily  disagreeable,  preliminary  stages,  as 
short,  and  as  little  unpleasant  as  possible.  In  mouth  and  throat  cases 
it  is  sometimes  desirable  that  the  body  should  be  raised  to  an  angle  of 
45°.  To  this  I  see  no  objection,  provided  that  the  legs  are  kept  horizontal. 

The  Choice  of  the  Anaesthetic.— To  a  considerable  extent  the 
comfort  of  both  patient  and  operator,  and  to  some  extent  the  actual 
safety  of  the  patient,  depends,  not  only  upon  the  skill  of  the  administrator, 
but  also  upon  the  particular  anaesthetic  used.  As  far  as  the  choice  of  the 
anaesthetic  is  concerned,  the  patient,  the  operator,  and  the  anaesthetist 
himself  are  all  factors  which  have  to  be  considered  before  making  the 
final  selection,  so  that  it  is  almost  impossible  to  do  more  than  lay  down 
very  general  rules  ;  each  individual  case  must  be  decided  upon  its  own 
merits. 

In  the  first  place,  it  is  obvious,  that  rules  that  are  intended  for  those 
with  whom  it  is  not  a  matter  of  absolutely  every-day  experience  to 
administer  an  anaesthetic  cannot  have  the  same  weight  when  applied 
to  the  specialist.  An  example  of  this  is  seen  in  the  use  of  ether.  When 
plenty  of  practice  in  the  administration  of  this  drug  is  obtainable,  it 
may  be  given  in  the  majority  of  cases  ;  but,  on  the  other  hand,  when 
only  used  very  occasionally,  the  results  are  apt  at  first  to  be  disappoint- 
ing, unless  the  cases  are  carefully  selected.  In  the  second  place,  some 
surgeons  object  to  the  use  of  particular  anaesthetics  in  certain  operations  ; 
for  example,  some  surgeons  consider  that  chloroform  alone  should  be 
given  in  all  cases  of  abdominal  section.  Under  these  circumstances,  it 
is  probably  to  the  best  interests  of  the  patient  to  adopt  the  views  of  the 
surgeon  ;  the  latter  ought  not  to  be  allowed  to  feel,  or  even  to  imagine, 
that  his  work  would  have  been  better  done,  had  a  different  anaesthetic 
been  used.  In  the  third  place,  it  may  be  laid  down  as  an  axiom,  that  it 
is  unwise  to  employ  a  stronger  anaesthetic  than  is  absolutely  necessary. 
The  relative  strength  of  the  various  substances  may  be  assumed  to  be  as 
follows,  commencing  with  the  most  feeble,  viz.  :  nitrous  oxide,  ether, 
diluted  chloroform  (as  in  the  A.C.E.  and  other  Mixtures),  pure  chloro- 
form and  ethyl  chloride. 

Factors  determining  Choice  of  Anaesthetic. — In  choosing  an  anaesthetic, 


PRELIMINARY  OBSERVATIONS  447 

the  most  important  of  the  determining  factors  are  those  which  concern 
the  patient  and  the  nature  and  probable  duration  of  the  operation  to  be 
performed  ;  these  must,  therefore,  be  considered  more  in  detail.  A  dis- 
tinction, too,  must  be  drawn  between  the  anaesthetic  with  which  it  is 
advisable  to  induce  or  commence  the  anaesthesia,  and  that  with  which  it 
is  possible  to  maintain  or  continue  it. 

(1)  Duration  of  the  Operation. — Either  nitrous  oxide  or  ethyl  chloride 
is  available  in  operations  of  under  three  minutes.     These  include  such 
operations  of  minor  surgery  as  opening  superficial  abscesses,  dilating  and 
slitting  up  sinuses,  some  tenotomies,  removing  small  aural  polypi,  passive 
movement  of  stiff  joints,  and,  of  course,  the  extraction  of  teeth. 

(2)  Position  of  the  Patient. — Neither  chloroform,  nor  any  mixture 
containing  that  drug,  should  be  used  with  the  patient  sitting  up  in  a 
chair  ;  such  a  proceeding  is  absolutely  unjustifiable.     Operations  upon  the 
cerebral  hemispheres,  and  upon  the  mouth  and  tongue,  do  not  really 
constitute  exceptions  to  this  general  rule,  for  although  the  body  is  then 
often  raised,  the  feet  and  legs  remain  horizontal. 

(3)  Age  of  the  Patient. — Some  anaesthetists  see  no  objection  to  the 
use  of  ether  at  any  age,  while  others  prefer  to  induce  narcosis  with  chloro- 
form in  the  very  young,  and  continue  with  ether  afterwards.     Until 
sufficient  facility  in  the  use  of  ether  has  been  acquired,  and  unless  one 
has  constant  practice  with  the  drug,  it  is  better  to  adopt  some  such  age- 
limits  as  the  following : 

Under  3  years  of  age       .          .     Chloroform  all  through. 
From  3  to  12  .          .          .     Mixture  all  through. 

From  12  to  60        .          .          .     Ether  all  through. 

Over  60          ....     Induce  with  Mixture,  increasing  the  pro- 
portion of  ether  in  long  operations. 

It  is  usually  asserted,  somewhat  dogmatically,  that  children  always 
take  chloroform  well.  It  must  not  be  forgotten,  however,  that  many 
accidents  have  occurred,  and  that  in  the  opinion  of  some  people  the 
death-rate  with  children  is  as  high,  or  even  higher,  than  with  adults. 
This  apparent  immunity  of  children  from  fatal  accidents  under  chloroform 
is  due  to  many  causes,  among  which  may  be  mentioned  the  undoubted 
fact  that,  owing  to  their  greater  vitality,  children  respond  more  readily 
than  adults  to  any  efforts  that  are  made  in  the  direction  of  resuscitation. 

(4)  Condition  of  the  Patient— Here,  again,  some  anaesthetists  admit 
of  but  few  exceptions  to  the  use  of  ether,  only  perhaps  acute  lung  troubles, 
but,  at  first  at  any  rate,  better  results  will  be  obtained  if  the  range  of 
exceptions  is  somewhat  enlarged. 

In  the  fat  and  plethoric  .  .  Induce  with  Mixture  and  gradually  in- 
crease the  proportion  of  ether  in  long 
operations. 

Acute    or    very     recent     lung 
troubles  .         .     Chloroform  all  through. 


448  ANESTHETICS 

Chronic  lung  trouble  (bronchitis 

or  emphysema    .          .          .     Mixture  all  through. 

Organic  heart  disease      .          .     If  insufficiently  compensated  (pulmonary 

oedema,  anasarca,  albumen,  etc.),  Mix- 
ture, or  chloroform.  If  fully  compen- 
sated, ether  permissible. 

Marked  Atheroma  .         .          .     Induce  with  Mixture  ;    add  a  little  ether 

if  the  operation  be  a  prolonged  one. 

Renal  Disease         .          .          .     Mixture  all  through. 

Alcoholics  take  all  anaesthetics  badly.  In  acute  or  advanced  cases 
it  is,  perhaps,  better  to  commence  with  Mixture,  and  gradually  increase 
the  proportion  of  ether  as  the  case  proceeds. 

(5)  Nature  of  the  Operation. — To  a  great  extent,  the  influence  of 
the  nature  of  the  operation  upon  the  choice  of  the  anaesthetic  must  be 
largely  determined  by  the  opinion  of  the  surgeon  upon  the  subject.  It  is, 
therefore,  a  point  of  no  little  importance  that  the  latter  should  have 
complete  confidence  in  the  administrator.  The  careful  selection  of  the 
administrator  is  a  question  of  the  greatest  moment,  and  not  to  be  dis- 
missed lightly  ;  to  take  any  one  that  offers  is  very  unjust  to  the  patient , 
and  accounts  for  many  of  the  troubles  and  fatalities  which  are  from  time 
to  time  recorded. 

Operations  upon  the  head  and  neck     Mixture  to  induce,  increasing  the  pro- 
portion of  ether  in  long  operations. 

Intra-cranial  operations      .          .     Chloroform  or  Mixture  all  through. 
Operations  upon  the  tongue  and 

mouth     .....     Induce  with  Mixture ;  change  for  chloro- 
form directly  operation  commenced. 

Operations  on  big  joints     .          .     Always  ether,  if  possible. 
Abdominal  operations         .          .     Often  do  well  with  ether,  but  chloro- 
form or  Mixture  generally  preferred 
by  surgeons. 

Rectal  and  genito-urinary  opera- 
tions      .....     Always  ether,  if  possible. 

In  practice,  the  choice  of  the  anaesthetic  may  be  quickly  determined 
by  adopting  a  process  of  exclusion,  taking  the  different  substances  in  the 
order  of  their  relative  strength,  as  given  on  p.  446. 

ADMINISTRATION  OF  NITROUS  OXIDE. 

Properties. — The  chemical  constitution  of  Nitrous  Oxide  is  sufficiently 
indicated  by  the  formula  N20.  It  is  a  gas,  but  is  usually  sold  in  a  highly 
compressed,  liquid  form,  in  steel  or  iron  bottles  (Fig.  197,  A).  The  gas, 
when  pure,  should  be  quite  colourless,  of  a  slightly  sweetish  taste  and 
odour,  and  unirritating  to  the  air  passages.  It  is  a  feeble  anaesthetic,  and 
is  usually  given  without  any  admixture  with  air,  i.e.  100%  of  the  vapour. 
When  sufficient  skill  has  been  attained  in  the  use  of  Nitrous  Oxide  in  the 
ordinary  way,  it  will  be  found  advantageous  to  allow  the  admixture  of 
small  quantities  of  air  during  its  inhalation,  but  this  requires  much  practice. 


ADMINISTRATION  OF  NITROUS  OXIDE 

Cases  Suitable.— Broadly  speaking,  anyone  can  take  nitrous  oxide 
with  comparative  safety,  but  I  object  myself  to  giving  it  to  very  young 
children.  It  is  better,  perhaps,  not  to  administer  it  within  an  hour  or 
so  of  a  full  meal,  and  care  should  be  taken  that  the  bladder  is  empty 
especially  in  children,  but  otherwise,  no  special  preparation  is  needed 
beyond  that  which  is  necessary  to  ensure  free  respiration  (see  p.  445)' 
It  is  most  frequently  given  with  the  patient  sitting  straight  up  in  a  chair' 
with  the  head  in  such  a  position  that  the  tongue  does  not  slip  back  over  the 
glottis  ;  it  may,  of  course,  be  given  with  the  patient  recumbent.  For  the 
cases  in  which  it  is  specially  applicable,  see  sec.  (i),  p.  447.  In  dental 
work,  and  in  operations  about  the  mouth,  it  is  usual  to  insert  a  prop  of 
wood  or  cork  between  the  teeth  before  applying  the  facepiece. 


FIG.  197. — NITROUS  OXIDE  APPARATUS.  A,  Steel  bottles  containing  compressed  gas 
in  liquid  form  ;  B,  Reservoir  bag ;  E,  Facepiece  ;  F,  Footpiece  for  regulating  escape 
of  gas  from  the  bottles  into  reservoir  bag  ;  C,  Three-way  stop-cock  with  inspiratory 
and  expiratory  valves. 

Although  in  some  respects  an  ideal  anaesthetic,  there  are  many  limita- 
tions to  its  use;  the  most  important  of  these  is  that,  owing  to  its  feeble 
anaesthetising  power,  .it  is  difficult  to  maintain  the  narcosis  for  any  length 
of  time,  and  practically,  therefore,  its  administration  is  limited  to  cases  in 
which  the  single  application  of  the  facepiece  will  suffice.  On  an  average, 
this  represents  between  30  and  40  seconds,  but,  with  a  little  careful  mani- 
pulation and  an  occasional  supply  of  air,  provided  that  the  operation  is  not 
upon  the  mouth,  this  time  can  easily  be  doubled  or  trebled.  Another 
objection  to  it  is,  that  the  relaxation  of  the  muscles  is  usually  very  transi- 
tory, and,  when  the  inhalation  is  pushed,  there  may  be  actual  spasm  ;  in 
moving  stiff  joints,  therefore,  it  is  of  importance  not  to  continue  the 
inhalation  for  too  long  a  time  without  admitting  air. 

Apparatus  and  Administration. — To  ensure  the  complete  exclusion  of 
air,  the  somewhat  complicated  apparatus,  shown  and  described  in  Fig.  197, 


G  a 


450  ANESTHETICS 

is  used.  The  bag  B  being  filled  with  gas,  the  administrator  stands  either 
behind  or  on  the  left  side  of  the  patient,  and  carefully  adjusts  the  face- 
piece  E  to  the  irregularities  of  the  face.  Being  satisfied  that  there  is  no 
air  leakage,  the  stop-cock  C  is  turned  half-way ;  the  nitrous  oxide  is 
then  inspired  from  the  bag,  and  expired  through  the  valves  contained  in 
the  stop-cock  into  the  open  air. 

Phenomena. — After  a  very  few  respirations  the  colour  of  the  face 
commences  to  change,  becoming  more  and  more  dusky,  or  uniformly  livid- 
Gradually,  too,  the  breathing  becomes  harsher,  and  changes  to  a  regular 
snore,  which,  in  its  turn,  gives  place  to  an  irregular,  jerky,  laryngeal 
stertor ;  at  or  about  the  same  time,  or  sometimes  even  before  the  laryn- 
geal stertor  is  noticed,  twitching  of  the  superficial  muscles  of  the  eyelids, 
mouth,  neck,  etc.,  or  of  the  tendons  of  the  thumbs  and  fingers  will  be 
seen ;  and,  if  the  inhalation  were  to  be  continued  beyond  this,  well 
marked  jactitation  of  the  limbs,  or  even  opisthotonic  spasm  of  the  whole 
body,  would  result.  Usually,  but  not  always,  the  pupils  dilate,  and  the 
conjunctivas  may  become  insensitive  to  touch,  but  the  eye  reflex  is  not 
a  reliable  sign  of  the  sufficiency  of  the  anaesthesia.  Whichever  is 
first  observed,  the  irregular  laryngeal  stertor,  or  the  twitching  of  the 
muscles  and  tendons,  is  the  indication  for  withdrawing  the  facepiece. 
After  the  facepiece  has  been  withdrawn,  the  first  few  breaths  of  air  are 
followed  by  a  reactionary  redness  or  blush  about  the  face,  etc. ,  and  this  is 
an  important  landmark  for  the  administrator ;  not  until  it  occurs  is  he 
quite  free  from  anxiety. 

Complications. — The  action  of  nitrous  oxide  is  really  remarkably 
uniform,  and  complications  rare ;  but  accidents  have  happened,  and 
deaths  have  occurred  both  from  syncope  and  asphyxia.  It  should  be  a 
rule,  therefore,  to  keep  a  ringer  on  the  temporal  pulse,  both  during  the 
inhalation,  and  until  the  reactionary  flush  occurs  ;  if  the  pulse  disappear, 
the  patient  should  be  at  once  put  in  the  recumbent  position,  and  the 
ordinary  treatment  for  syncope  adopted.  Asphyxia  may  be  due  to  a 
foreign  body,  e.g.  a  tooth,  and  it  also  seems  likely  to  occur  in  patients 
suffering  from  acute  inflammation  of  the  fauces  and  trachea.  In  asphyxi- 
ated patients,  the  first  thing  to  do  is  to  pass  the  finger  well  to  the  back  of 
the  throat  to  free  the  air-way,  and  to  attempt  to  remove  any  foreign  body 
that  may  be  felt.  Failing  this,  the  patient  should  first  be  bent  sharply 
forward,  and  encouraged  to  cough  by  patting  the  back,  etc. ;  if  this  does 
not  give  relief,  he  must  be  taken  out  of  the  chair  and  laid  upon  his  side 
on  the  floor,  and,  if  this  fails  to  relieve  the  asphyxia,  tracheotomy,  or, 
better,  laryngotomy  must  be  done.  Hysterical  patients  sometimes  give 
trouble  from  the  beginning  by  struggling  and  screaming  ;  this  is  best  over- 
come by  compressing  the  reservoir  bag,  and  so  forcing  the  gas  into  the  lungs, 
taking  care,  of  course,  to  cut  off  the  action  of  the  valves  in  the  stop-cock. 
Children  and  anaemic  girls  are  apt  to  pass  quickly  and  deeply  under  the 
influence  of  the  gas,  and  to  become  opisthotonic  ;  the  facepiece,  therefore, 


ADMINISTRATION   OF  NITROUS   OXIDE 


45i 


should  be  removed   immediately   the    slightest    twitching    or  stertor 
occurs. 

The  after-effects  of  nitrous  oxide  may  be  said  to  be  practically  nil,  and 
this  is  one  of  its  great  advantages.  Neurotic  patients  are  sometimes 
hysterical,  very  rarely  there  is  a  little  sickness,  but,  in  by  far  the  majority 
of  cases,  the  patient  is  quite  able  to  leave  the  house,  or  walk  about  within 
ten  minutes  or  a  quarter  of  an  hour  of  the  inhalation. 

PROLONGED   NITROUS  OXIDE  ANESTHESIA.— Various  plans  have  been  suggested 

for    increasing   the  anaesthetising    power    of    nitrous    oxide    gas.     In    operations 

not  involving  the  mouth  or  nose,  the  anaesthesia  may  often  be  much  prolonged 

by  allowing  the  patient  an 

occasional     breath    of    air 

directly    the   twitching   ap- 
pears.    In  dental  and  other 

mouth  cases,  the  supply  of 

nitrous  oxide  may  be  main- 
tained by  means  of  a  cap 

fitted     over    the    nose,    as  '*' 

suggested  by  Coleman  and 

Paterson  (see  Fig.  198).     Of 

late  years  I  have  employed 

this   method    almost    as    a 

matter  of  routine  for  women 

and   children,   not   only   to 

maintain,  but  also  to  induce 

anaesthesia  for  dental  work. 

The  mouth  is  propped  open, 

the  cap  fitted  over  the  nose 

and  a  slight  plus  pressure  is  maintained  in  the  bag.     Contrary  to  what  might  be 

expected,  anaesthesia  is  apt  to  be  induced,  if  anything,  too  rapidly  and  the  patient 

must  be  carefully  watched.  In  adult  males,  and 
in  some  fat,  flabby  females  who  breathe  badly 
through  the  nose,  the  inhalation  should  be  started 
with  the  ordinary  facepiece,  quickly  changing 
the  latter  for  the  nosepiece  directly  the  twitching 
develops.  On  the  whole  I  have  found  this  plan 
extremely  satisfactory.  Other  forms  of  apparatus 
for  this  purpose  have  been  introduced  by  Trewby 
and  others. 

Adopting  the  view  that  the  lividity,  muscular 
twitching,  and  some  of  the  other  phenomena  are 
indications  of  oxygen  starvation,  and,  assuming 
that  these  phenomena  are  always  objectionable, 
it  has  been  proposed  to  administer  a  mixture  of 
nitrous  oxide  and  oxygen.  In  the  apparatus 
that  Sir  Frederic  Hewitt  has  designed  the 
nitrous  oxide  and  the  oxygen  are  contained 
in  separate  bags,  and  provision  is  made  for  very 
gradual  admixture  of  these  gases  through  small 
holes  in  the  stop-cock.  The  facepiece  being 
accurately  adjusted,  the  nitrous  oxide  mixed 

with  the  oxygen  from  one  or  two  holes  is  breathed  from  the  beginning,  and  the 


FIG.   198. — PATERSON'S    NOSEPIECE. 
and  valves.    C,  Nosepiece. 


A,     Three- way    stopcock 


FIG.  199.  —HEWITT'S  '  GAS  AND  OXY- 
GEN '  APPARATUS.  B  and  D,  double  bag 
for  oxygen  and  nitrous  oxide.  C,  three- 
way  tube  fitted  with  small  holes  for  regu  - 
lating  supply  of  oxygen.  E,  facepiece. 


452  ANESTHETICS 

amount  of  oxygen  is  increased  by  a  hole  or  two  at  a  time  as  the  inhalation 
proceeds.  The  indications  for  removing  the  facepiece  are  a  faint  stertor,  fixation 
of  the  eyeball,  and  insensibility  of  the  conjunctivas.  The  method  is  most  suited 
for  elderly  or  anaemic  subjects  or  those  whose  circulatory  or  respiratory  systems 
are  feeble,  but  the  apparatus  is  cumbersome,  and  unpleasant  after-effects  are 
rather  more  likely  to  follow  than  when  nitrous  oxide  is  administered  in  the 
ordinary  way. 

The  period  of  available  anaesthesia  may  also  be  prolonged  by  mixing  the  gas 
with  some  other  and  more  powerful  anaesthetic,  such  as  ether.  This  is  what  is 
known  as  the  '  combined  '  or  '  gas-and-ether  '  method  of  anaesthesia,  which  will  be 
referred  to  after  the  administration  of  ether  has  been  described  (see  p.  457). 


ADMINISTRATION  OF  ETHER. 

Properties. — Ethylic  or  sulphuric  ether  (C4H10O)  is  a  liquid  of  which 
the  spec.  grav.  should  be  0720 ;  it  is  neutral  to  test-paper,  and  leaves 
neither  stain  nor  smell  when  burnt  off  or  evaporated.  It  is  usually  re- 
commended to  employ  only  that  made  from  absolute  alcohol ;  but  many 
excellent  brands  are  now  on  the  market,  which,  if  carefully  selected, 
seem  unobjectionable.  The  so-called  '  anaesthetic  ether  '  of  chemists  is 
intended  only  for  freezing,  and  should  never  be  used  for  inhalation. 
Ether  vapour  is  highly  inflammable,  and  even  explosive  when  mixed 
with  air  or  nitrous  oxide.  Over  30  per  cent,  of  the  vapour  is  necessary 
to  produce  narcosis  within  a  reasonable  time. 

Cases  Suitable. — It  is  considered  by  many  that  ether  should  be  em- 
ployed whenever  an  anaesthetic  is  called  for  ;  practically,  the  only  excep- 
tions which  are  then  admitted  are  those  in  which  bronchitis  or  some  other 
acute  lung  trouble  is  present,  or  when,  as  in  operations  about  the  mouth, 
it  is  either  physically  impossible  to  apply  the  facepiece,  or  else  there 
is  some  danger  that  the  actual  cautery  will  ignite  the  vapour.  For  the 
reasons  given  above  (see  p.  446) ,  this  universal  use  of  ether  is  at  first  likely 
to  prove  disappointing  to  those  not  thoroughly  accustomed  to  the  drug. 
When  only  occasionally  called  upon  to  anaesthetise,  it  is  better  for  the 
administrator  to  limit  his  use  of  ether  in  accordance  with  the  suggestions 
already  made  (see  p.  447).  If  these  lists  be  carefully  studied,  it  will  be 
seen  that  ether  is  not  recommended  for  children  under  twelve,  or  for  adults 
over  sixty  ;  nor  for  the  fat  and  plethoric  ;  nor  for  those  suffering  from 
gross  cerebral  lesions ;  nor  in  cases  of  lung  disease  ;  nor  in  acute  heart 
disease,  atberoma,  or  renal  disease ;  nor  in  operations  about  the  head  and 
neck,  mouth  and  tongue.  At  first  sight,  it  may  appear  that  this  list  of 
exceptions  reduces  the  available  cases  to  a  minimum,  but  in  practice  this 
will  not  be  found  to  be  the  case,  and,  further,  it  must  be  pointed  out, 
that  in  by  far  the  majority  of  cases  the  objection  applies  rather  to  the 
primary  induction  ;  in  nearly  all  it  is  possible  to  use  ether  to  maintain  the 
anaesthesia. 

Ether  should  always  be  given,  if  possible,  in  cases  involving  much 

GBTfcG    "iG    5fj3J. 


ADMINISTRATION  OF  ETHER 


453 


shock,  and  in  which  a  profound  degree  of  narcosis  is  required,  as  in 
operations  about  the  rectum,  on  the  genito-urinary  tract,  or  on  big  joints. 
Operations  upon  the  abdomen  are  on  the  border-line,  and  the  anaesthetic 
chosen  must  be  largely  determined  by  the  predilection  of  the  surgeon 
(see  p.  446). 

With  regard  to  the  preparation  of  the  patient,  nothing  need  be  added 
to  what  has  already  been  said  upon  the  subject  (see  p.  443).  It  is  one  of 
the  advantages  of  ether,  which  is  sometimes  overlooked,  that,  if  need  be,  it 
can  be  administered  to  a  patient  sitting  up,  without  much  additional  risk  ; 
preference  should,  however,  always  be  given  to  the  recumbent  position, 
as  the  increased  muco-salivary  secretion  can  then  be  got  rid  of  more  easily. 

Apparatus   and  Administration. — In  an  emergency,  an  inhaler   for 


FIG.  200.— CLOVER'S  SMALL  OR  PORT- 
ABLE  ETHER  APPARATUS.  C,  Ether 
chamber  ;  S,  Opening  through  which  the 
chamber  is  filled  with  2  oz.  of  ether  ;  F, 
Padded  facepiece  ;  B,  Reservoir  bag  ;  p, 
Pointer.or  index,  which  is  a  fixture.  To 
increase  the  proportion  of  ether  inhaled, 
the  chamber  is  rotated  so  as  to  bring  the 
figures,  i,  2,  etc.,  over  the  index  in 
succession. 


ether  can  be  made  by  twisting  two  or  three  folds  of  brown  paper 
into  a  cone,  like  a  grocer's  sugar-bag,  pushing  a  wide-meshed  sponge 
well  up  into  the  apex  of  the  cone,  and  tearing  off  the  extreme  tip  to 
admit  air;  the  ether  is  poured  upon  the  sponge.  Of  course,  better 
results  will  be  obtained  when  a  properly  constructed  inhaler  is  used. 
In  Fig.  200,  the  well-known  Clover's  (small  and  portable)  Inhaler  is 
shown.  Two  ounces  of  ether  are  poured  into  the  ether  chamber  through 
the  opening  S.  The  inner  tube,  with  the  facepiece  attached,  is  thrust  up 
through  the  corresponding  opening  in  the  ether  chamber,  the  index  p 
carefully  adjusted  to  the  mark  0  on  the  body  of  the  chamber,  and 
facepiece  F  placed  over  the  mouth  and  nose  of  the  patient.  After  a  few 
breaths  have  been  taken,  and  the  patient  has  become  accustomed  to  the 
apparatus,  the  bag  B  is  fixed  to  the  end  of  the  inner  tube  which  will 
found  flush  with  the  upper  opening  in  the  ether  chamber.  A  few  breath  s 
in  and  out  of  the  bag  are  allowed,  and  then,  during  an  expiration,  t 
body  of  the  chamber  is  gently  rotated,  either  to  the  right  or  to  the  left, 


454 


ANESTHETICS 


for  the  space  of  about  a  quarter  of  an  inch,  or  even  less  ;  a  few  more 
breaths  being  allowed,  another  rotation  of  about  the  same  extent  is  made. 
These  movements  are  repeated  at  short  intervals  until,  finally,  the  index 
points  to  about  the  2,  at  which  position  it  is  maintained  until  a  suffici- 
ently profound  degree  of  narcosis  is  obtained.  Each  movement  of  the 
ether  chamber  should  be  made  during  an  expiration,  and  no  additional 
onward  movement  should  take  place  so  long  as  there  is  any  coughing, 
spasm,  or  other  indication  that  the  vapour  is  producing  irritation.  It  is 
seldom,  if  ever,  necessary  to  give  a  greater  strength  of  vapour  than  that 
indicated  above,  and,  in  fact,  when  the  primary  skin  incisions  have  been 
made,  and  the  patient  has  become  quiet,  and  saturated  with  ether,  it  is, 
advisable  to  diminish  the  strength  of  the  vapour  by  turning  the  ether 
chamber  back  towards  the  i,  or  even  to  remove  the  bag  altogether. 

The  Open  and  Semi-open  Methods. — Of  late  years  some  adminis- 
trators have  urged  that  better  results  are  obtained  by  dispensing  altogether 

with  the  bag,  and  simply  spreading  the  ether 
over  an  evaporating  surface  held  just  above 
the  nose  and  mouth.  In  America,  where  this 
practice  is  particularly  in  vogue,  an  Allis's 
inhaler  (see  Fig.  201)  is  employed,  or  one  of 
the  masks,  figured  on  p.  465,  can  be  used; 
this  is  the  semi-open  method.  In  the 
completely  open  method  a  Skinner's  or  a 
Schimmelbusch's  frame  is  used  (see  Fig.  205) 
as  for  chloroform.  In  either  method  the 
supply  of  ether  to  the  evaporating  surface 
must  be  continuous.  It  is  claimed  for  these 
plans,  that  as  there  is  no  obstruction  to  the 
breathing,  there  is  less  lividity.  The  period 
of  induction  is  however  prolonged,  the 
amount  of  ether  used  very  large,  and  the 
atmosphere  unpleasantly  saturated  with 
the  vapour.  Bronchitis  and  '  water-logging ' 
are  by  no  means  abolished,  though  it  is 

maintained  by  some  that  these  may  be  much  diminished  by  the  prior 
injection  of  atropine  (gr.  yJ^).  It  is  certainly  of  service  in  children  and 
old  people  and  to  maintain  the  anaesthesia  induced  by  other  means. 

It  is  usual  to  divide  the  process  of  ansesthetisation  into  four  stages,  but 
it  must  be  understood  that  this  arrangement  is  somewhat  artificial ;  clini- 
cally, the  different  stages  overlap  one  another,  and  are  not  equally  well 
denned  in  every  case.  These  stages  are  : — First,  the  stage  of  confusion  of 
ideas,  with  subjective  sensations  of  dizziness,  tingling  of  the  extremities, 
etc.  Second,  the  stage  of  excitement  and  more  or  less  struggling.  Third, 
the  stage  of  anaesthesia,  with  flaccidity  of  the  limbs,  slow  movements  of  the 
eyeballs  from  side  to  side,  abolition  of  the  conjunctival  and  other  super- 


FIG.  20i.— ALLIS'S  INHALER.  This 
consists  of  a  mask  of  leather  laced 
round  a  metal  frame  of  many  ribs ; 
over  these  ribs  is  wound  a  long  strip 
of  flannel,  domette,  or  some  such 
material.  The  ether  is  poured  in  a 
small  continuous  stream  on  the 
flannel. 


ADMINISTRATION   OF  ETHER  455 

ficial  reflexes;  but  the  deeper  reflexes  are  retained,  so  that  there  is  still  the 
power  of  coughing  and  swallowing,  and,  when  the  skin  incisions  are  made, 
the  muscles  are  apt  to  be  thrown  into  spasm.  The  fourth  stage  is  char- 
acterised by  more  markedly  stertorous  breathing,  dilated  pupils,  fixation 
of  eyeballs,  and  abolition  of  all  reflexes,  both  superficial  and  deep.  As  a 
general  rule,  the  fourth,  or  most  profound  degree  of  anaesthesia,  is  kept  up 
only  while  the  primary  incisions  are  made,  after  which  the  patient  may 
be  allowed  to  fall  back  to  the  third  degree ;  but  in  cases  where  con- 
siderable shock  is  to  be  anticipated,  as  in  operations  upon  the  abdomen, 
on  the  large  joints,  in  the  genito-urinary  areas,  etc.,  it  is  of  great 
importance  that  the  anaesthesia  should  be  maintained  fairly  deeply 
throughout. 

There  are  three  special  points  in  connection  with  ether  anaesthesia 
which  must  be  noted.  If  the  vapour  be  introduced  too  rapidly,  or  its 
strength  increased  too  suddenly,  some  temporary  laryngeal  spasm,  with 
more  or  less  coughing  and  straining,  will  very  likely  ensue  ;  if  this  does  not 
disappear  in  the  course  of  a  few  respirations,  air  must  be  admitted  and 
the  proportion  of  vapour  diminished.  It  is  generally  possible  to  induce 
anaesthesia  with  but  little  alteration  in  the  colour ;  for  the  first  four  or 
five  minutes,  however,  some  slight  lividily  is  excusable,  but  it  is  quite 
a  mistake  to  suppose  that  persistent  and  marked  blueness  is  of  necessity 
associated  with  the  use  of  ether ;  such  a  condition  means  either  bad 
administration,  or  that  the  patient  is  not  a  fit  subject  for  this  particular 
drug.  Directly  the  colour  commences  to  change,  air  must  be  admitted 
beneath  the  edge  of  the  facepiece,  and  if,  in  spite  of  the  free  admission 
of  air,  the  lividity  persists,  or  sufficiently  profound  anaesthesia  cannot 
be  obtained,  it  is  wisest  to  change  the  anaesthetic.  The  third  point  is, 
that  there  is  a  considerable  increase  in  the  flow  of  mucus  and  saliva  ;  as 
soon,  therefore,  as  the  muscles  of  the  neck  become  sufficiently  relaxed, 
the  head  must  be  turned  to  one  side,  so  as  to  encourage  this  excessive 
secretion  to  flow  into  the  cheek,  and  so  out  of  the  mouth.  This  is 
much  facilitated  by  tucking  the  corner  of  a  towel,  or  a  tampon  of  lint 
into  the  cheek. 

The  essential  characteristic  of  ether  anaesthesia  is  the  stimulation.  The 
respirations  increase  in  frequency  and  depth,  and,  partly  on  account  of 
the  presence  of  mucus  in  the  air  passages,  they  are  usually  noisy.  The  pulse 
becomes  quicker,  of  greater  volume,  and  improved  in  tone  ;  an  erythe- 
matous  flush  (ether  rash)  often  appears  over  the  neck,  chest,  and  arms, 
and  may  be  so  well  marked,  and  so  extensive,  as  to  be  mistaken  at  first 
sight  for  one  of  the  exanthemata.  The  pupils  are  widely  dilated  during 
the  stage  of  excitement  and  struggling,  moderately  contracted  during  the 
comparatively  light  anaesthesia  of  the  middle  of  the  third  stage,  but 
tending  to  dilate  as  the  narcosis  becomes  deeper ;  unless  this  dilatation 
takes  place  very  suddenly,  it  is  not  of  necessity  a  sign  of  danger,  as  in  the 
case  of  chloroform. 


456  ANESTHETICS 

The  chief  dangers  in  connection  with  the  administration  of  ether  are 
of  an  asphyxial  type.  The  muco-salivary  secretions  may  be  so  excessive 
that  the  lungs  may  become  '  water-logged/  the  heart's  action  seriously 
embarrassed,  and  the  venous  system  engorged.  The  careful  administrator 
ought  never  to  allow  a  patient  to  get  into  this  serious  condition  ;  the  free 
admission  of  air,  or  if  this  fails,  the  substitution  of  another  anaesthetic, 
should  not  be  delayed  when  once  the  tendency  is  apparent.  The  accumu- 
lation of  mucus  may  often  be  checked  at  the  outset,  by  permitting  the 
patient  to  come  round  just  sufficiently  to  allow  of  his  swallowing,  or  even, 
when  it  is  permissible,  vomiting.  If,  however,  the  condition  of  '  water- 
logging '  has  arisen,  the  anaesthetic  must  be  withheld,  the  mouth  opened, 
the  tongue  pulled  forward,  the  mucus  sponged  out  from  the  throat, 
vomiting  encouraged,  and,  finally,  the  patient  must  be  turned  on  his  right 
side  ;  it  is  in  such  cases  as  these,  that  the  administration  of  oxygen  is 
especially  called  for.  In  the  earlier  stages  of  ether  narcosis,  primary 
cardiac  syncope  seldom,  if  ever,  occurs  as  a  direct  result  of  the  inhalation, 
although,  of  course,  the  mere  dread  of  the  operation  may  have  this  effect ; 
on  the  other  hand,  cases  are  on  record  in  which  death,  occurring  at  a  later 
period,  appears  to  have  been  due  to  over-stimulation  of  the  heart,  and, 
perhaps,  of  the  respiratory  centre.  If,  then,  while  the  patient  is  well 
under,  the  breathing  becomes  more  rapid  and  shallower,  the  inhalation 
should  be  suspended  for  a  short  time  until  the  normal  condition  is 
restored. 

With  the  Clover's  inhaler,  the  time  occupied  in  producing  anaes- 
thesia must,  of  course,  vary  very  considerably ;  from  four  to  six 
minutes  may  be  taken  as  a  good  working  average.  From  a  calculation 
based  upon  544  cases,  in  which  both  the  duration  of  the  operation,  and  the 
quantity  of  ether  used  was  noted,  one  ounce  of  ether  was  estimated  to 
last,  on  an  average,  io-4  minutes.i 

After-effects. — If  the  patient  has  not  been  more  than  about  a  quarter 
of  an  hour  or  twenty  minutes  under  the  anaesthetic,  he  passes,  on  discon- 
tinuing the  inhalation,  through  the  stages  already  referred  to  (see  p.  454), 
but  in  reverse  order,  viz.,  comparatively  light  anaesthesia,  excitement, 
gradually  returning  consciousness.  In  any  event,  one  of  the  first  after- 
effects is  usually  the  vomiting  of  mucus,  often  frothy  and  ropy,  and  fre- 
quently bile-stained.  With  ether,  this  is  apt  to  be  very  severe  during 
the  first  hour  or  two,  but  as  the  patient  is  but  partly  conscious,  it  is  really 
less  distressing  to  him  than  at  first  sight  appears.  As  soon  as  he  can  do 
so,  the  patient  should  be  encouraged  to  wash  out  his  mouth  with  warm 
water,  and  sips  of  hot  water  should  be  swallowed.  In  some  cases, 
especially  if  there  has  been  little  or  no  sickness,  more  or  less  violent 
delirium  is  observed.  The  frequency  with  which  serious  pulmonary 
troubles  occur  after  the  use  of  ether  has  probably  been  greatly  exaggerated. 

1  King's  College  Hospital  Reports,  vols.  vi.  and  vii. 


ADMINISTRATION  OF  ETHER 


457 


On  the  other  hand,  there  can  be  no  doubt  that  the  inhalation  of  ether 
renders  the  lungs  particularly  susceptible  to  alterations  in  temperature, 
draughts,  etc.  Consequently,  some  bronchial  irritation  may  occasionally 
follow  the  inhalation.  It  is  wise,  therefore,  to  order  that  the  temperature 
of  the  room  should  not  be  allowed  to  drop  below  65°  R,  that  screens  should 
be  placed  round  the  bed,  and  that  for  the  first  few  hours  at  any  rate, 
the  patient  should,  if  possible,  be 
kept  lying  on  one  side,  by  preference 
the  right.  This  latter  manoeuvre  not 
only  assists  the  escape  of  saliva, 
from  the  mouth,  but,  I  believe,  also 
facilitates  the  onward  flow  of  the 
stomach  contents  through  the  pyl- 
orus, and  so  diminishes  the  tendency 
to  retching  and  sickness.  Occasion- 
ally, '  water-logging,'  and  the  effects 
of  over-stimulation  (see  p.  456)  do 
not  manifest  themselves  until  after 
the  patient  has  been  put  back  to 
bed,  and  fatal  results  have  been 
recorded  from  these  causes  at  this 
stage  ;  patients  should,  therefore,  be 
strictly  watched  by  a  responsible 
person,  for  at  least  an  hour  or  more 
after  the  completion  of  the  opera- 
tion. For  a  more  detailed  reference 
to  after-treatment  see  p.  477. 

NITROUS  OXIDE  AND  ETHER  COMBINED. 
— The  so-called  COMBINED  METHOD  is  the 
plan  of  inducing  anaesthesia  with  nitrous 
oxide,  and  maintaining  the  narcosis  with 
ether  (nitrogenising  the  ether).  The  pro- 
cedure is  as  follows,  viz.  : — If  the  Clover's 
inhaler  be  used,  the  three-way  tube  and 
bag  of  the  nitrous  oxide  apparatus  are 
substituted  for  the  smaller  ether-bag  (Fig. 
202).  About  half  a  dozen  full  respira- 
tions of  the  nitrous  oxide  are  allowed, 
and  then  the  ether  vapour  is  cautiously 
admitted,  by  rotating  the  ether  chamber. 
When  once  the  ether  is  tolerated,  the 

increase  in  the  strength  of  the  vapour  may  be  much  greater,  and  made  at  shorter 
intervals  than  when  ether  alone  is  being  administered.  When  irregular  stertor  and 
twitching  of  the  muscles  appear,  the  nitrous  oxide  must  all  be  pressed  out  of  the 
bag,  and  a  breath  or  two  of  air  given,  or,  perhaps  a  better  plan  is,  to  change  the  large 
for  the  smaller  bag  at  this  stage.  It  is  as  well  to  point  out  that  a  good  deal  of 
practice  is  required  before  uniformly  satisfactory  results  are  obtained.  The 
point  to  be  aimed  at  is  the  turning  on  of  the  ether  at  such  a  rate,  that  a  full  dose 


Fie.  202. — CLOVER'S  PORTABLE  ETHER  AR- 
PARATUS,  FITTED"  FOR  NITROCS  OXIDE  AMD 
ETHER  COMBINED.  A,  Steel  gas  bottles ;  B, 
Reservoir  bag  ;  C,  Three-way  stop-cock  connect- 
ing gas  bag ;  D,  Ether  chamber ;  E,  Facepiece. 


458  ANESTHETICS 

is  being  inhaled  at  the  precise  moment  when  the  muscular  twitching,  etc.,  due  to  the 
nitrous  oxide,  are  first  observed. 

It  is  claimed  for  the  combined  method  that  it  is  far  more  pleasant  for  the 
patient,  as  he  is  unconscious  of  the  irritating  and  disagreeable  taste  and  smell  of 
the  ether  ;  that  it  is  much  more  rapid  ;  that  to  a  great  extent  it  does  away 
with,  or  considerably  modifies  the  excitement  and  struggling,  and  so  enables  us  to 
dispense  with  the  help  of  others  in  restraining  the  patient. 

Ether  is  also  frequently  used  in  dental  work  for  the  purpose  of  intensifying  the 
action  of  nitrous  oxide  (etherising  the  nitrous  oxide).  The  Clover's  apparatus 
may  be  used  for  this  purpose,  and  the  procedure  is  practically  the  same  as  already 
detailed,  except,  that  the  patient  is  allowed  to  get  more  fully  under  the  influence 
of  the  nitrous  oxide,  and  the  ether  is  turned  on  more  rapidly.  I  believe  myself,  that 
in  this  use  of  ether,  the  local  effect  of  the  vapour  upon  the  buccal  mucous  membrane 
is  largely  responsible  for  the  prolongation  of  the  anaesthesia. 


ADMINISTRATION  OF  CHLOROFORM. 

Strictly  speaking,  one  ought  now  to  describe  the  administration  of 
diluted  chloroform  in  the  shape  of  the  Mixtures  (A.C.E.,  etc.),  as  these  rank 
next  above  ether  in  anaesthetic  strength.  To  avoid  repetition,  however, 
chloroform  anaesthesia  will  first  be  referred  to. 

Properties.— Chloroform  has  a  chemical  formula  of  CHC13.  Its  spec, 
grav.  should  be  1*497,  and  chloroform  made  from  pure  alcohol  should 
be  used  in  preference  to  the  so-called  methylated  chloroform  for  anaesthetic 
purposes.  Unless  carefully  protected  from  heat  and  sunlight,  it  is  apt  to 
decompose.  It  should  be  quite  colourless  ;  neutral  to  test  paper  ;  leav- 
ing no  disagreeable  smell  or  coloured  residue  on  evaporation  ;  giving  no 
precipitate  with  a  solution  of  nitrate  of  silver  ;  and  not  turning  brown  on 
mixing  with  an  equal  volume  of  pure  sulphuric  acid.  The  vapour  is 
upwards  of  four  times  as  heavy  as  air,  uninflammable,  but  decomposing 
into  highly  irritating  gases  when  passed  through  or  brought  into  contact 
with  a  flame.  Hence  it  is  important,  when  operating  at  night,  or  in  small 
rooms  in  the  presence  of  a  naked  flame,  to  secure  a  full  and  adequate 
amount  of  ventilation.  Chloroform  is  one  of  the  strongest  anaesthetics  that 
we  possess  ;  above  4  per  cent,  of  the  vapour  constitutes  a  dangerous  dose. 

While  with  nitrous  oxide  or  with  ether,  special  means  have  to  be 
adopted  to  obtain  a  sufficient  percentage  of  the  vapour ;  with  chloro- 
form, on  the  other  hand,  the  greatest  attention  must  be  paid  to  securing 
a  sufficient  supply  of  air. 

Cases  Suitable. — If  the  suggestions  already  made  (see  p.  447)  as  to  the 
alternative  use  of  the  several  drugs  be  adopted,  it  will  be  found  that  the 
use  of  undiluted  chloroform  is  specially  indicated  in  such  cases  as  the 
following,  viz. — Infants,  and  very  young  children  of  one  or  two  years  of 
age  and  in  people  over  60  ;  those  suffering  from  acute  or  very  recently 
acute  lung  trouble  ;  in  parturition,  where  only  a  partial  action  seems  to 
be  required ;  in  operations  about  the  nose  and  mouth,  to  maintain  the 
anaesthesia  induced  by  other  anaesthetics ;  in  proximity  to  the  actual 


ADMINISTRATION  OF  CHLOROFORM 


459 


cautery  ;  in  cerebral  cases  ;  and  most  surgeons  now  prefer  this  drug  alone 
for  abdominal  work.  Chloroform  enters  largely,  however,  into  the  com- 
position of  the  A.C.E.  and  other  mixtures,  so  that  practically  it  still 
retains  a  prominent  place  in  the  list  of  available  anaesthetics. 

The  preparation  of  the  patient  should  be  carried  out  strictly  on  the 
lines  suggested  on  p.  443,  and,  with  regard  to  position,  an  emphatic  protest 
must  be  entered  against  any  attempt  being  made  to  administer  chloroform 
to  a  patient  sitting  in  a  chair.  This  protest  is  necessary,  because  it  is  still 
occasionally  used  for  tooth  extraction  with  the  patient  in  the  ordinary 
dental  position.  When  chloroform  is  inhaled  the  patient  should  be 
recumbent,  his  legs  horizontal  and  and  his  body  not  raised  above  45°. 

Apparatus  and  Administration. — The  simplest  way  to  administer 
chloroform,  and  at  the  same  time  ensure  a  sufficient  supply  of  air,  is  to 
sprinkle  it  drop  by  drop  by  means  of  a  suitable  drop- 
bottle  (Fig.  203),  on  to  the  outside  of  a  folded  towel 
(Fig.  204),  or  on  to  a  handkerchief,  or,  better  still,  on 
to  a  piece  of  domette  stretched  tightly  over  a 
metal  frame  (Sehimmelbuseh's  Inhaler)  (Fig.  205). 
Personally,  I  object  to  the  use  of  lint,  the  woolly  sur- 
face of  which  quickly  becomes  sodden,  and  renders 
the  equable  distribution  of  the  vapour  almost 
impossible. 

By  some,  the  Junker's  Inhaler  (Fig.  204)  is  pre- 
ferred. The  principle  of  this  apparatus  is  simply 
that  of  blowing  air  through  a  layer  of  liquid 
chloroform,  by  means  of  a  hand-bellows,  the  mix- 
ture of  air  and  vapour  being  conveyed  to  a  face- 
piece.  Variations  in  the  strength  of  the  vapour 
are  determined  by  the  force  and  frequency  with 
which  the  bellows  are  pressed.  Care  must  be  taken  that  the  liquid 
chloroform  does  not  more  than  half  fill  the  bottle,  and  that  the  bellows- 


FIG.  203.  —  CHLORO- 
FORM DROP  -  BOTTLE 
WITH  HOLLOW  STOPPER. 


FIG.  204.    TOWEL  FOLDED  FOR  ADMINISTRATION  or  CHLOROFORM. 

tube  and  the  exit-tube  are  fitted  to  their  respective  metal  connections- 
Fatal  accidents  have  occurred  from  neglecting  these  points,  as  liquid 
chloroform  is  then  poured  into  the  patient's  mouth. 

Whichever  method  be  employed,  it  must  be  constantly  borne  in  mi 
that  care  and  vigilance,  on  the  part  of  the  administrator,  are  much  more 
important  elements  of  success  than  is  the  use  of  any  particular  apparatus. 


460  ANESTHETICS 

Excellent  results  may  be  obtained  by  any  plan  that  is  systematically 
studied  and  employed. 

With  chloroform,  as  with  every  other  anaesthetic,  it  is  very  important 
to  commence  the  inhalation  gradually.  The  evaporating  surface  must, 
at  first,  be  held  four  or  five  inches  from  the  face,  and  only  brought  close 
over  the  nose  and  mouth  as  consciousness  is  abolished  and  toleration 
established.  If  there  be  any  retching,  as  may  sometimes  happen  even 
in  the  earlier  stages,  the  anaesthetic  should  be  pressed,  when  the  retching 
will  often  cease  ;  but  if  vomiting  has  actually  taken  place,  and  the  con- 
tents of  the  stomach  have  regurgitated  into  the  mouth,  the  anaesthetic 
must  be  withdrawn,  the  mouth  opened,  and  the  vomited  matter  removed. 
The  stage  of  excitement  and  unconscious  struggling  requires  careful 
management.  The  condition  of  mental  and  physical  turmoil  is  un- 
doubtedly a  dangerous  one,  and  should  not  be  allowed  to  become  unduly 
prolonged.  On  the  other  hand,  the  deep  inspirations  which  the  patient 

sometimes  takes  are  apt  to 
overcharge  the  lungs  with 
vapour,  and  so  to  lead  to 
sudden  respiratory  and  circu- 
latory failure.  The  best  plan, 
I  believe,  is  to  give  the  anaes- 
thetic freely  at  these  times,  but 
making  sure,  by  raising  the 
inhaler,  etc.,  that  the  amount 

FIG.  205.— SCHIMMELBUSCH'S  INHALER.  of     air     is      proportionately    in- 

creased.     It  is  dangerous,  with 

chloroform  especially,    to    bring  the  inhaler  closer  to  the  face  while 
struggling  is  proceeding. 

The  phenomena  observed  during  the  induction  of  anaesthesia  with 
chloroform  are  very  similar  to  those  already  alluded  to  in  describing 
ether  anaesthesia  (see  p.  454).  The  stage  of  excitement  is  perhaps  less 
marked  and  of  shorter  duration,  and  it  is  followed  by  a  period  of  depres- 
sion, in  which  the  blood  pressure  falls,  the  pulse  becomes  smaller  and 
weaker,  and  the  respiration  shallower.  During  the  stage  of  excitement 
the  pupils,  as  a  rule,  dilate  rather  widely,  and  this  dilatation  may  con- 
tinue, especially 'in  young  children  and  in  the  neurotic,  for  a  considerable 
length  of  tune,  if  not  during  the  whole  period  of  narcosis  ;  usually,  how- 
ever, the  pupil  during  the  third  stage  is  moderately  contracted,  i.e. 
rather  smaller  than  with  ether.  During  the  fourth  stage,  the  pupil  tends 
to  dilate,  often  suddenly,  and  this  is  an  indication  that  the  narcosis  is  of 
dangerous  depth.  Then,  again,  a  rather  widely  dilated  pupil  is  often 
the  precursor  of  vomiting,  which  cannot  of  course  occur  unless  the  patient 
be  but  lightly  anaesthetised.  These  alterations  in  the  size  of  the  pupils, 
when  rightly  interpreted,  afford  valuable  information  to  the  administrator, 
but  at  the  same  time  it  is  obvious,  that  we  cannot  rely  upon  the  pupil 


ADMINISTRATION  OF  CHLOROFORM 


461 


phenomena  alone  as  indications  of  the  exact  state  of  the  patient.  Occa- 
sionally during  induction,  and  especially  in  children,  the  patient  passes 
imperceptibly  into  a  curious  and  anomalous  condition  of  anaesthetically 
induced  sleep,  or  false  anesthesia  ;  the  pupils  are  sharply  contracted, 
the  limbs  are  quite  flaccid,  the  superficial  reflexes  abolished,  and  it  is  not 
until  the  deeper  reflexes  are  excited,  as  by  the  skin  incision,  that  we  are 
able  to  recognise  the  fact  that  the  state  is  in  reality  one  of  light  anaesthesia. 
The  ideal  condition  of  a  patient  under  chloroform  should  be  some- 
what as  follows,  viz.  :  colour  good,  or  slightly  pallid ;  respirations 
regular,  fairly  deep,  slightly  accelerated,  quiet,  or  with  a  slight,  soft 
snore  ;  eyeballs  fixed  or  rotating  very  slowly  from  side  to  side,  pupils 
moderately  contracted  and  sluggishly  sensitive,  cornea!  conjunctivas  in- 
sensitive. The  greatest  variations  from  this  standard  will  be  found  in 
the  very  young  and  the  very  old — in  old  people  the  respirations  and 


FIG.  206. — JUNKER'S  INHALER. 

pulse  rate  may  both  be  very  much  below  the  average.  It  is  impossible, 
however,  to  refer  in  detail  to  all  the  variations  which  may  be  observed. 
Very  occasionally  in  quite  young  infants,  an  undue  strength  of  vapour 
will  give  rise  to  some  slight  laryngeal  spasm.  Blueness  of  the  lips, 
cheeks,  ears,  etc.,  is  quite  unwarranted,  as  it  indicates  that  the 
vapour  is  in  far  too  great  a  strength,  and  air  must  at  once  be  supplied  ; 
some  patients  become  very  pale  under  any  anaesthetic  which  contains 
chloroform,  and,  if  this  pallor  is  gradually  displaced  by  an  ashy-grey 
hue,  it  is  an  indication  that  the  circulation  is  failing,  and  the  anaesthetic 
must  be  at  once  withdrawn,  and,  if  need  be,  more  energetic  measures 
taken  (see  p.  473).  The  respirations  must  be  watched  with  the  greatest 
possible  vigilance,  and  variations  in  the  rapidity  and  depth  should  be 
detected  early.  I  would  lay  particular  stress  upon  the  importance  of 
maintaining  the  expiratory  phase  of  the  respiratory  cycle.  Elimination 
of  the  vapour  is  more  difficult  to  secure  than  inhalation.  Quick,  shallow 
breathing  may  end  in  total  cessation  of  respiration,  and  is  an  indication 
for  diminishing  the  strength  oi  the  vapour,  or  even  withdrawing  it  for 


462  ANESTHETICS 

a  time  altogether.     The  treatment  to  be  adopted  when  the  breathing 
does  stop  will  be  described  presently  (see  p.  473). 

Pure  chloroform,  unmixed  with  ether,  should  not,  theoretically,  give 
rise  to  noisy  or  stertorous  respirations,  and  certainly  noisy  breathing 
which  cannot  be  rectified  by  slight  changes  in  the  position  of  the  head, 
pushing  forward  the  base  of  the  tongue,  by  pressure  upon  the  angles  of 
the  inferior  maxilla  or  lifting  the  chin  upwards,  must  not  be  allowed. 
There  is  practically  no  increase  in  the  flow  of  mucus,  etc. 

The  essential  characteristic  of  chloroform  anaesthesia  is  the  depression. 
Thus,  paralysis  of  the  respiratory  centre  is  probably  the  most  usual  cause 
of  death  in  fatal  cases,  though  cardiac  failure  is  not  unknown.  This 
tendency  to  respiratory  failure  sets  in  very  early,  and  makes  it  more  than 
usually  imperative  that  the  respiration  should  be  most  carefully  watched, 
at  the  same  time  as,  but  even  more  vigilantly  than  the  circulation.  It 
is  probable  that  respiratory  failure  is  usually  associated  with  cardiac 
failure,  though  not  always  part  passu.  As  Lord  Lister  has  pointed  out,i 
the  breathing  may  become  obstructed  by  the  falling  together  of  the 
relaxed  soft  tissues  about  the  air  passages,  and  this  condition  has  an 
important  bearing  upon  the  treatment,  as  will  subsequently  be  explained 
(see  p.  473). 

On  an  average,  between  six  and  eight  minutes  is  a  fair  time  to 
allow  for  inducing  anaesthesia  with  chloroform  by  the  above  method. 
It  is  said  by  some,  that  the  quantity  of  chloroform  used  should  be  at 
about  the  rate  of  3j  for  'every  ten  minutes  of  anaesthesia,  but  such 
estimates  are  unreliable,  as  it  is  obvious  that  the  amount  must  vary 
enormously  in  accordance  with  such  opposite  conditions  as  the  age  of  the 
patient,  his  state  of  health,  the  heat  of  the  weather,  the  thickness  of  the 
towel,  etc. 

The  special  after-effects  of  chloroform  differ  in  degree  rather  than  in 
kind  from  those  observed  as  a  consequence  of  the  use  of  ether.  The 
vomiting  may  not  be  so  severe,  but  it  often  does  not  set  in  until 
consciousness  is  more  or  less  completely  restored,  and  therefore  the 
feeling  of  wretchedness  is  prolonged.  Bronchitis  and  other  lung  affec- 
tions are  rare  sequelae  to  chloroform  inhalation,  nor  is  delirium  at  all 
frequent.  For  a  more  detailed  account  of  after-treatment,  see  p.  477. 

Dosimetrie  Methods. — The  last  few  years  have  seen  a  revival  of  the 
practice  of  administering  chloroform  by  means  of  inhalers,  furnished 
with  close  fitting  face-pieces  and  valves,  with  the  object  of  regulating 
the  strength  of  vapour  supplied.  The  construction  of  modern  inhalers 
is  based  upon  the  view,  that  anaesthesia  can  be  induced  and  maintained 
with  much  smaller  quantities  of  chloroform  than  was  at  one  time 
thought  possible  ;  that  these  small  percentages  are  capable  of  accurate 
measurement  and  regulation,  and  that  a  knowledge  of  these  percentages 

1  Holmes,  System  of  Surgery,  vol.  iii. 


ADMINISTRATION  OF  MIXTURES 


463 


added  in  some  way  to   the  safety  of  the  patient,  and  the  comfort 
of  all  concerned. 

The  inhaler  which,  at  the  present 
moment,  is  most  in  vogue,  is  that  known 
as  the  Vernon-Harcourt  Inhaler,  figured 
and  described  in  Fig.  207. 

Considerable  practice  with  this  machine 
is  required  before  its  intricacies  are 
mastered.  Its  best  results,  however,  are 
very  satisfactory,  and  it  is  said  to  be 
useful  more  particularly  for  long  cases 
in  the  old  and  feeble,  in  whom,  too,  the 
tendency  to  shock  may  be  still  further 
diminished  by  passing  a  stream  of  oxygen 
through  the  apparatus.  Those  who  pro- 
pose to  give  this  inhaler  a  trial  should  be 
warned,  that  the  period  of  induction  is 
often  prolonged  to  ten  or  fifteen  minutes ; 
the  indicated  percentages  cannot  be  relied 
upon,  as  they  vary  considerably  with  the 
temperature  of  the  room,  the  angle  which 
the  chloroform  bottle  assumes,  its  steadi- 
ness, the  accuracy  of  the  various  valves, 
and  probably  with  the  force  of  the  re- 
spirations. As,  too,  the  anaesthesia  is  very 
light,  the  patient  must  be  watched  with 
more  than  the  usual  vigilance  in  order  to 
avoid  his  coming  round  in  the  middle  of 
the  operation. 

Other  forms  of  apparatus  have  been  devised  in  which  known  volumes 
of  air  are  made  to  take  up  measured  quantities  of  chloroform,  the  patient 
breathing  the  mixture  out  of  a  storage  bag.  These,  however,  are  at 
present  too  cumbersome  for  clinical  use. 

ADMINISTRATION  OF  MIXTURES   (A.C.E.  ETC.). 

From  the  point  of  view  of  anaesthetic  strength,  the  mixtures  occupy 
a  position  intermediate  between  ether  and  chloroform.  Of  such  mixtures 
there  may,  of  course,  be  an  infinite  variety,  according  to  the  relative  pro- 
portion of  the  constituents,  but  to  certain  stock  mixtures  definite  names 
have  been  attached  ;  thus,  a  combination  of  one  part  of  chloroform  to 
three  of  ether  is  known  as  the  'Vienna  mixture,'  while  'Billroth's 
mixture'  consists  of  three  parts  of  chloroform,  one  of  ether,  and  one 
of  absolute  alcohol.  In  this  country,  however,  'the  A.C.E.  mixture,' 
or,  as  it  is  often  called,  '  the  mixture,'  is  the  term  by  which  is  usually 
indicated  a  fluid  composed  of  absolute  alcohol  spec.  grav.  0795  one  part 


FIG.  207. — VERNON  -  HARCOURT  IN- 
HALER. A,  Chloroform  bottle.  B,  In- 
spiratory  valve  for  chloroform.  C, 
Inspiratory  valve  for  air.  D,  Regulator. 
The  proportion  of  vapour  varies  in 
accordance  with  the  proximity  of  the 
pointer  to  the  chloroform  bottle.  Th-! 
course  of  the  vapour  is  indicated.  E, 
facepiece  and  expiratory  valve. 


464  ANESTHETICS 

by  volume,  chloroform  spec.  grav.  1*497  two  parts,  and  ether  spec.  grav. 
0720  three  parts  ;  it  is  usually  looked  upon  as  merely  a  mechanical 
mixture  of  its  constituents. 

Properties. — Its  spec,  grav.,  when  freshly  prepared,  is  as  nearly  as 
possible  the  mean  of  its  three  constituents,  i.e.,  ro  ;  the  spec.  grav.  of  its 
vapour  has  not  been  experimentally  determined.  The  particular  purpose 
served  by  the  alcohol  is  not  very  clear  ;  possibly  the  advantage  is  mainly 
mechanical,  leading  to  a  more  intimate  admixture  of  the  several  con- 
stituents, but  it  is  also  claimed  that  the  evaporation  of  the  ether  is  some- 
what retarded.  It  is  said  to  be  somewhat  unstable,  and  it  is  always 
recommended  that  it  should  be  freshly  prepared,  as  required.  Of  late 
years  I  have  been  in  the  habit  of  employing  a  mixture  of  one  part  of 
chloroform  and  two  of  ether,  i.e.  the  same  relative  amount  of  chloro- 
form, rather  more  ether  and  no  alcohol.  An  advantage  of  this  combina- 
tion is  that  its  constituents  are  more  likely  to  be  at  hand  when  a  fresh 
supply  is  wanted.  I  usually  mix  it  in  the  operating  room  for  each  case. 

Advantages. — The  question  is  often  asked,  why  the  mixture  should  be 
preferred  to  pure  chloroform.  The  reply  to  this  query  is  founded  partly 
upon  theoretical,  partly  upon  practical  considerations.  Theoretically,  I 
am  inclined  to  believe  that  the  stimulating  effects  of  the  ether  vapour, 
however  slight,  cannot  but  be  of  service,  and  that,  by  using  a  moderately 
diluted  vapour,  there  is  much  less  risk  of  overstepping  the  narrow  margin 
of  safety  which  is  so  characteristic  of  chloroform  anaesthesia.  Practically, 
I  am  sure  that,  with  the  mixture,  one  obtains  earlier  notice  of  impending 
danger  than  with  chloroform  alone.  Neither  the  mixture  nor  any  of 
the  anaesthetics  at  present  known  are  absolutely  safe,  but  the  danger 
with  the  A.C.E.  is  chiefly  that  of  over-narcosis  pure  and  simple,  and  of 
this  more  ample  warning  is  given  than  with  chloroform ;  to  a  great 
extent,  though  perhaps  not  entirely,  the  element  of  sudden  over-dilata- 
tion of  the  heart  is  eliminated. 

Cases  Suitable. — When  neither  nitrous  oxide  nor  ether  are  advisable, 
the  next  anaesthetic  to  be  considered  is  a  mixture.  The  list  of  objections 
to  the  use  of  ether,  therefore,  given  on  p.  452,  constitutes  a  list  from  which 
cases  suitable  for  the  use  of  mixture  can  be  selected.  But  even  the  small 
amount  of  ether  contained  in  the  mixture  may  be  considered  harmful 
in  those  actually  suffering  from  extensive  lung  disease  ;  when  the  actual 
cautery  is  to  be  employed  in  close  proximity  to  the  inhaler ;  and  as  an 
inhaler  is  usually  employed,  it  is  not  easy  to  maintain  the  narcosis  with 
mixtures  in  operations  about  the  mouth  and  nose. 

The  preparation  of  the  patient  should  be  carried  out  on  the  lines 
suggested  on  p.  443,  and  no  position  is  permissible  but  the  recumbent, 
or  one  on  which  the  legs  are,  at  least,  on  the  level  of  the  body. 

Apparatus  and  Administration. — No  form  of  closed  or  bag-inhaler 
should  be  used  for  A.C.E.  or  other  chloroform  mixture.  In  very  small 
children,  and  in  neurotic  adults,  it  may  be  given  by  the  open  method,  i.e. 


ADMINISTRATION  OF  MIXTURES  465 

by  dropping  on  an  open  mask  (p.  460)  or  on  a  handkerchief  held  just 
above  the  mouth.  Generally  speaking,  however,  an  inhaler  is  desirable  - 
a  useful  form  is  the  metal  mask  depicted  below  (Fig.  208)  This 
apparatus  is  made  of  metal,  and  can  be  purified  in  lotions  or  by  heat 
The  sponge  is  retained  in  position  by  means  of  a  wire  guard  Fig  200  (B) 
and  a  shield  set  at  an  angle  (A)  prevents  the  liquid  from  running  on 
The  hinged,  perforated,  concave  top  (D)  is  convenient  for 
charging  without  removing  from  the  face.  It  is  important  that  a  very 
free  supply  of  air  should  be  available,  so  the  ventilation  holes  must  be 
large  (J  in.)  and  numerous,  and  the  facepiece  ought  not  to  fit  over 
the  nose  and  mouth  with  any  great  accuracy,  and  for  this  reason  a  padded 
facepiece  is  objectionable.  Anaesthesia  maybe  maintained  or  even  induced 
with  ether  in  these  masks,  if  necessary. 


FIG.  208. — METAL   INHALER 


MIXTURES. 


-C 


FIG.  209. — METAL  INHALER,  IN  SECTION.  A, 
Shield  ;  B,  Wire  guard ;  C,  Sponge ;  D,  Per- 
forated top. 


In  the  actual  administration  two  points  are  to  be  particularly  attended 
to,  viz.  :  Use  small  quantities  of  the  mixture  frequently  repeated,  rather 
than  one  or  two  large  doses.  By  this  means,  the  stimulating  effects  of 
the  ether  are  more  nearly  continuous  than  when  a  large  quantity  of  the 
liquid  is  used  at  a  time.  Secondly,  in  this,  as  in  all  other  methods  of 
inducing  general  anaesthesia,  it  is  important  to  commence  the  inhalation 
very  gradually,  holding  the  facepiece  a  few  inches  from  the  face  to 
begin  with,  and  gradually  bringing  it  nearer  as  the  vapour  is  better 
tolerated. 

The  chief  objections  which  have  been  urged  against  the  use  of  the 
mixture  are  as  follows,  viz.  :  it  is  sometimes  said  that  an  over-strong 
vapour,  consisting  chiefly  of  chloroform,  is  apt  to  accumulate  in  the 
mask  below  the  sponge.  The  possibility  of  this  occurring  cannot  be 
doubted,  and  the  remedy  is  equally  obvious.  The  mask  must  not  fit 
the  face  at  all  closely,  and  must  be  supplied  with  plenty  of  large  air-holes, 
and  the  anaesthetic  must  be  added  in  small  quantities  (3j — 3ij)  at  a 
time.  Under  this  head,  too,  must  be  included  the  objection,  that  the 


i:  H 


466  AN^STHETHICS 

different  constituents  of  the  mixture  evaporate  at  different  temperatures. 
This,  of  course,  is  true,  but  experience  has  shown  that  the  consequent 
slight  variations  in  the  composition  of  the  vapour,  do  not  militate  against 
the  practical  efficacy  of  the  mixture. 

Bearing  in  mind  that  the  most  potent  constituent  of  the  A.C.E.,  and 
most  other  mixtures,  is  the  chloroform,  it  is  only  natural  that  the 
phenomena  observed,  and  the  precautions  to  be  adopted  in  their  adminis- 
tration, are  but  modifications  of  those  already  described  under  the  head 
of  the  latter  drug.  Owing  to  the  stimulating  effect  of  the  ether — which 
should  be  almost  continuous,  if  small,  frequently  repeated  doses,  mixed 
with  plenty  of  air,  be  given — the  depressing  effects  of  the  chloroform  are 
less  apparent.  On  the  other  hand,  laryngeal  spasm  is  of  slightly  more 
frequent  occurrence  in  children,  and  as  the  flow  of  mucus  is  increased, 
the  breathing  is  apt  to  be  a  little  more  noisy.  The  ether-rash  (see  p.  455) 
is  occasionally  observed,  and  the  pupils  are,  on  the  whole,  inclined  to  be 
rather  more  widely  dilated  than  with  chloroform  in  the  third  stage  of 
anaesthesia. 

The  dangers  and  after-effects  are  essentially  those  of  chloroform  (see 
p.  471),  but  as  they  are  rather  more  gradual  in  their  onset,  they  can 
usually  be  detected  before  the  condition  of  the  patient  becomes  serious. 
There  appears  to  be  less  fear  of  early  cardiac  syncope. 

In  cases  lasting  more  than  about  three-quarters  of  an  hour,  I  often 
increase  the  proportion  of  ether  in  the  mixture  by  gradual  additions  of 
that  drug. 

About  1 1  ounce  should  suffice  to  induce  anaesthesia  ;  in  children  less 
will  be  required.  Five  to  seven  minutes  should  be  allowed  for  the  pro- 
duction of  the  primary  narcosis.  From  a  calculation  based  upon  2801 
cases,  in  which  both  the  duration  of  the  operation  and  the  amount  of 
mixture  used  was  noted,  one  ounce  of  A.C.E.  was  estimated  to  last  on 
an  average  15-6  minutes  (King's  Coll.  Hosp.  Rep.,  vols.  vi.,  vii.  and  viii.). 

ETHYL  CHLORIDE  (C2H.,C1)  is  a  colourless  liquid  with  a  somewhat  pungent, 
but  not  disagreeable  odour.  It  evaporates  at  a  temperature  of  12-5°  C.  (52-5°  F.), 
and  the  vapour  is  very  inflammable.  It  forms  the  basis  of  many  of  the  proprietary 


FIG.  210.— CHLORIDE  OF  ETHYL  TUBE. 

articles  used  for  the  production  of  anaesthesia  by  freezing,  such  as  Anestile,  Kelene, 
Narcotile,  etc.,  and  it  is  the  chief  contsituent  of  '  Somnceform.' 

It  is  usually  sold  in  glass  tubes  containing  about  50  c.c.,   fitted  with  a  spring 
stopper  (Fig.  210).  When  the  minute  hole  in  the  nozzle  is  uncovered,  the  heat  of 


ADMINISTRATION  IN  SPECIAL  CASES  467 

the  hand  suffices  to  drive  out  a  capillary  stream  of  the  liquid,  which  may  either  be 
used  for  freezing  or  directed  into  a  proper  receptacle  for  inhalation.  It  is  also  sent 
out  m  hermetically  sealed  capsules  of  3  or  5  c.c.,  which  may  be  broken  as  required 

When  employed  by  itself  for  inhalation,  3-5  c.c.  are  dropped  into  a  bag  or 
other  form  of  closed  inhaler.  Its  action  is  very  rapid  and  complete,  but  as  some 
fatalities  have  attended  its  use  it  has  lately  fallen  into  disrepute.  I  believe  myself 
that  these  accidents  are  largely  due  to  faulty  methods  of  administration ;  such  a 
powerful  drug  ought  not  to  be  administered  in  a  closed  inhaler  or  bag.  For  some 
years  I  have  used  it  almost  invariably  as  a  preliminary  to  the  introduction  of  the 
mixture,  and  have  had  practically  no  trouble  with  it  My  plan  is  to  spray  from 
8  to  10  c.c.  on  the  sponge  of  a  mask  (Fig.  208)  from  below,  apply  it  the  face, 
and  directly  the  breathing  becomes  slightly  stertorous,  or  there  are  any  other 
indications  of  loss  of  consciousness,  pour  a  full  dose  (Jj — 3iss)  °*  t^e  A.C.E.  or 
similar  mixture  on  the  sponge,  from  above.  The  chief  advantage  of  this  method 
is  the  rapidity  with  which  consciousness  is  abolished  ;  I  think,  too,  that  the  stage 
of  excitement  is  always  curtailed,  and  often  disappears  completely. 


ADMINISTRATION  IN   SPECIAL   CASES. 

Under  certain  conditions,  some  slight  departure  from  the  ordinary 
routine  methods  of  administration  seems  to  be  desirable,  but  space  will 
not  permit  of  more  than  a  passing  reference  to  these  cases,  and  this 
reference  may  most  conveniently  take  the  form  of  indicating  my  own 
practice  in  the  matter. 

In  intra-cranial  operations,  anaesthesia  is  induced  in  the  recumbent 
position,  and  the  body  is  raised  slowly  and  cautiously  to  an  angle  of 
about  45°.  Chloroform  or  a  mixture  is  used  throughout,  and  only  just 
enough  anaesthetic  is  given  to  keep  the  patient  quiet.  His  disease 
renders  him  very  susceptible  to  an  over-dose,  and  at  the  same  time 
makes  him  less  susceptible  to  actual  pain. 

Operations  about  the  Nose  and  Mouth.— In  such  short  opera- 
tions upon  the  nasal  passages  as  the  removal  of  turbinated  bodies, 
etc.,  the  operator  often  considers  it  better  for  the  patient  to  be 
sitting  up,  in  which  case,  of  course,  nitrous  oxide,  with  or  without  the 
addition  of  oxygen  or  ether,  is  the  best  anaesthetic,  and  as  soon  as  possible 
the  body  should  be  pushed  well  forward,  so  that  the  head  may  hang  over 
a  basin  placed  between  the  knees,  when  the  blood  will  run  out  of  the 
nose  and  mouth.  A  somewhat  similar  position  and  procedure  will,  in 
the  opinion  of  some  surgeons,  suffice  for  the  removal  of  tonsils  or  adenoids, 
but  when  the  choice  is  left  to  the  anaesthetist,  I  must  confess  that  I  have 
a  preference  for  the  plan  of  lightly  anaesthetising  the  patient  in  the  re- 
cumbent position  with  Mixture,  and  turning  him  on  the  right  side  as  the 
operation  proceeds. 

Use  of  Junker's  Inhaler  with  Tube.— In  long  operations  about  the 
buccal  cavity,  e.g.,  removal  of  the  tongue,  I  prefer  to  induce  anaesthesia 
to  a  tolerably  profound  degree  with  Mixture,  and  to  maintain  it  with 


H  H  2 


468  ANAESTHETICS 

chloroform  given  out  of  a  Junker's  inhaler  (Fig.  206)  in  which  the  face- 
piece  has  been  removed  and  a  tube  substituted.  The  tube  (Fig.  211) 
should  have  an  internal  diameter  of,  at  least,  four  millimetres  (they  are 
generally  much  too  narrow),  and  may  be  passed  down  the  nose  if  necessary. 
Some  administrators  prefer  to  very  thoroughly  saturate  the  patient  with 
ether  for  five  or  six  minutes  before  the  operation  is  commenced,  and 
then,  if  need  be,  continue  with  chloroform.  My  own  experience  is  that 
ether  causes  undue  congestion  and  bleeding,  and  the  increased  flow  of 
mucus  still  further  obscures  the  field  of  operation,  and  increases  the 
tendency  to  asphyxia.  In  the  more  delicate  operations  in  this  region, 
e.g.  sub-mucous  resections  of  the  septum-nasi,  chloroform  should  be 
used  from  the  beginning.  The  practice  of  different  surgeons  varies 
considerably  in  respect  to  the  position  adopted  for  the  performance  of 
these  operations.  Many  surgeons  prefer  that,  whenever  possible,  the 
patient  should  be  absolutely  recumbent,  the  head  being  allowed  to  hang 
over  the  end  of  the  table,  with  the  neck  extended,  so  as  to  bring  the 
post-nasal  space  into  a  dependent  position.  Personally,  I  am  doubtful 

whether  much  is  really  gained  by 
this,  and  I  am  quite  sure  that  the 
bleeding  is  more  profuse,  and  that 
the  stretching  of  the  muscles  and 
tissues  of  the  neck  causes  much 

FJG.    211. — MOUTH  TUBE   OF    STOUT   METAL.  .  ..  ,  „.,.. 

At  least  4  mm.  in  calibre.  after-discomfort.    Others,  again,  like 

to  have  the  head  and  shoulders  well 

raised,  and  perhaps  the  chin  strongly  flexed  towards  the  sternum.  There 
are  still  others  who  place  the  patient  sitting  almost  bolt  upright ;  this 
position  is  not,  perhaps,  without  some  risk,  and  is  not  an  ideal  one  for 
the  anaesthetist,  but  I  must  admit  that  after  much  experience  I  have 
never  seen  trouble  arise  from  its  adoption.  It  is  essential,  however,  that 
the  feet  and  legs  should  be  well  elevated,  and  the  body  arranged  for 
rapid  lowering  should  signs  of  syncope  present. 

In  such  delicate  operations  as  those  for  cleft  palate,  the  dorsal  position, 
with  the  head  more  or  less  extended,  is  imperative,  so  as  to  obtain  the 
best  view  possible  of  the  parts.  In  these  cases,  too,  some  surgeons  of 
great  experience  consider  that  healing  is  retarded  by  the  direct  impact 
of  the  chloroform  vapour  from  the  tube  upon  the  freshly  cut  edges  of 
the  wound,  and  they  prefer  to  maintain  the  anaesthesia  by  means  of 
chloroform  dropped  upon  a  towel  or  lint ;  but  direct  impact  of  the 
vapour  ought  to  be  easily  avoided,  and  when  this  is  done  it  is  difficult 
to  understand  why,  if  the  patient  be  kept  well  under,  the  use  of  the  towel 
or  lint  should  be  less  injurious. 

In  using  the  Junker's  apparatus  W7here  the  breathing  is  likely  to  be 
obstructed,  it  is  important  to  bear  in  mind  that  the  heavy  vapour  of 
chloroform  is  apt  to  accumulate  at  the  back  of  the  throat,  directly  the 
breathing  becomes  in  the  slightest  degree  obstructed,  so  that  the  energy 


ADMINISTRATION   IN  SPECIAL  CASES 


469 


with  which  the  bellows  should  be  worked  must  be  directly  proportionate 
to  the  freedom  of  respiration. 

In  extensive  operations  upon  the  base  of  the  tongue,  etc.,  when 
preliminary  tracheotomy  is  advisable,  a  Hahn's  or  Trendelenburg's 
tampon  is  sometimes  inserted  (Fig. 
212),  the  anaesthesia  being  then 
maintained  through  the  tracheal 
opening.  By  some  surgeons  laryn- 
gotomy  is  preferred  in  these  cases. 
No  tampon  is  used,  and  the  anaes- 
thetic is  administered  through  the 
tube  by  means  of  a  Junker's  inhaler 
and  tube  attachment. 

Patients  with  enlarged  thy- 
roids are  very  liable  to  sudden  attacks  of  syncope  while  taking 
anaesthetics,  but,  on  the  other  hand,  it  is  really  remarkable  what  a 
very  small  quantity  of  anaesthetic  will  suffice  to  keep  such  patients 
thoroughly  under.  In  thyroidectomies,  therefore,  I  frequently  use 
a  Junker's  apparatus  throughout,  giving  but  very  little  of  the  anaes- 
thetic, only  just  enough  to  restrain  the  retching  and  vomiting  to 
which  such  patients  appear  to  be  particularly  prone.  Abroad, 


FIG.  212. — HAHN'S  TRACHEOTOMY  TAMPON. 


FIG.  213.— HAHN'S  CHLOROFORM  ATTACHMENT.    A,  Junction  with  tracheal  tube. 
B,  Metal  cone  covered  with  domette  on  which  the  chloroform  is  dropped. 

local  anaesthesia  in  the  shape  of  cocaine  is  largely  employed  in  these 
operations,  but   it  appears  to  be   quite  possible  that  the   success 
this  drug  in  these  cases  is,  in  some    measure,  due  to  the  differen< 
in  the  type   of  the  patients,  as   compared  with  those    seen  in  this 

country. 

In  all  these  operations  about  the  head  and  neck,  some 
experienced  in  preventing  the  hair  from  falling  into  the  wound,  and  in 


470 


ANESTHETICS 


keeping  the  blood  from  the  hair.     I  have  adopted  the  device  shown  and 
explained  in  Figs.  214  and  215. 


A.B 


FIGS.  214  AND  215. — PROTECTION  OF  HAIR  IN  OPERATIONS  IN  THAT  REGION. 
A  carbolised  towel  is  folded  cornerwise ;  the  middle  of  this  folded  edge  is  placed 
over  the  forehead,  the  ends  A  and  B  crossed  well  behind  the  occiput,  and  brought  up 
to  the  forehead  and  secured  by  a  pin.  The  end  C  may  be  utilised  for  securing  stray 
strands  of  hair.  The  appearance  will  be  as  in  the  right-hand  figure. 

In  abdominal  operations  many  surgeons  prefer  the  use  of  chloroform 
on  the  grounds  that  the  anaesthesia  is  quieter,  the  muscular  relaxation 
more  perfect,  and  the  after-sickness,  if  any,  is  less  violent.  If  ether  be 
used  for  these  cases  the  increased  flow  of  mucus,  associated  with  the 
temporary  paralysis  of  the  abdominal  muscles,  increases  the  risk  of 
bronchial  and  pulmonary  complications.  When  the  stomach  is  to  be 
opened  it  may  be  washed  out  with  a  stomach  tube,  but  this  should  be 
done  not  less  than  half  an  hour  beforehand  ;  it  is  of  no  advantage,  but 
rather  the  reverse,  to  do  this  at  the  last  moment,  or  when  the  patient 
is  actually  anaesthetised.  In  cases  of  faecal  vomiting  from  intestinal 
obstruction,  the  contents  of  the  stomach  may  be  siphoned  off  just  before 
the  operation. 

In  severe  operations  in  robust  adults  in  which  much  shock  is  to  be 
anticipated,  it  is  of  importance  that  the  anaesthesia  should  be  tolerably 
profound  throughout.  Among  such  operations  I  would  particularly 
enumerate  those  affecting  the  big  joints,  those  involving  manipulation  of 
the  spermatic  cord,  operations  upon  the  genito-urinary  and  rectal  areas, 
and  abdominal  operations.  When  patients  are  losing  much  blood,  or  are 
suffering  from  primary  shock  or  much  prostration,  the  strength  of  the 
vapour  inhaled  may  be  considerably  diminished.  It  is  in  such  cases 
that  nutrient  enemata  and  strychnine  hypodermically  are  useful,  and  in 
which  a  regulating  inhaler  is  of  advantage. 

Alcoholics  are  troublesome  subjects  to  anaesthetise.  They  are  apt 
to  struggle  very  violently,  to  become  very  livid,  and  unless  reduced  to  a 
dangerous  degree  of  narcosis,  they  are  often  very  restless.  This  is 
especially  the  case  when  ether  is  used.  Their  tissues  are  often  much 
degenerated,  so  that  in  choosing  an  anaesthetic  for  such  patients  it  must 
be  remembered  that  they  are  prematurely  aged.  Acute  or  far  advanced 
cases  should  perhaps  be  started  with  Mixture,  and  ether  gradually  added. 


DIFFICULTIES  AND  DANGERS  471 

In  this  connection  reference  must  be  made  to  the  condition  known  as 
the  status  lymphaticus.  By  this  is  meant  an  enlargement  of  the  thymus 
gland  and  a  general  hypertrophy  of  the  lymphatic  tissues  throughout  the 
body.  The  condition  is  an  undoubted  pathological  fact,  and  as  such 
has  been  held  to  be  sufficient  to  account  for  otherwise  inexplicable  cases  of 
sudden  death,  whether  occurring  on  the  operating  table  or  in  the  street. 
Persons  suffering  from  it  (mostly  children)  are  said  to  be  particularly 
susceptible  to  chloroform.  It  unfortunately  happens,  however,  that  the 
clinical  signs  and  symptoms  of  the  disease  are  so  very  indefinite,  that  it 
is  rarely  recognised  during  life,  and  it  is  more  than  probable  that  a 
large  number  of  children,  afflicted  in  this  way,  pass  through  the  ordeal 
of  an  operation  without  causing  the  slightest  anxiety  to  the  anaesthetist. 
The  possibility  of  the  existence  of  the  condition,  however,  is  another 
argument  in  favour  of  the  view  that  children  are,  if  anything,  more, 
rather  than  less,  susceptible  to  chloroform  than  adults,  and  that  corre- 
spondingly greater  care  should  be  taken  with  them. 


DIFFICULTIES  AND  DANGERS. 

Difficulties  and  dangers  directly  connected  with  the  anaesthetic  are 
due  to  the  effects  of  the  various  drugs  upon  either  the  respiratory  or  the 
circulator}^  systems.  Many  and  bitter  are  the  controversies  which  have 
arisen  as  to  which  system  is  primarily  affected,  but  much  of  this  discussion 
has  been  of  an  academic  rather  than  of  a  practical  character  ;  at  present, 
the  balance  of  opinion  appears  to  be  in  favour  of  ascribing  to  both 
functions  some  share  in  the  production  of  fatal  results.  At  any  rate,  it 
is  admitted,  on  all  hands,  that  the  depression  in  the  respiration,  even  if 
it  is  not  absolutely  coincident  with  the  circulatory  failure,  precedes  or 
follows  it  so  closely  that,  clinically,  it  is  almost  impossible  to  distinguish 
between  the  two  effects,  and,  therefore,  the  line  of  treatment  must  be 
such  as  will  give  relief  in  both  directions. 

Simple  syncope  appears  to  be  an  accident  to  which  patients  are  occa- 
sionally liable  in  the  very  earliest  stages  of  the  inhalation.  Some  such 
cases  are  undoubtedly  due  to  mere  fright,  and  can  hardly  be  ascribed  to 
the  toxic  effects  of  the  anaesthetic ;  but,  on  the  other  hand,  many  cases 
are  on  record  in  which  no  such  dread  of  the  operation  existed,  but  where, 
nevertheless,  the  patient,  often  a  strong  healthy  adult,  has  suddenly 
succumbed  after  inhaling  the  anaesthetic  for  a  few  minutes,  when  appa- 
rently unconscious,  and  passing  into  the  third  stage  (see  p.  454).  The 
existence  of  a  condition  of  status  lymphaticus  has  been  put  forward  in 
explanation  of  some  of  these  cases. 

In  origin,  respiratory  troubles  may  be  spasmodic,  asphyxial,  or 
due  to  the  toxic  effects  of  the  drug  upon  the  central  nervous  system. 
Spasm  of  the  glottis  may  occur  with  any  anaesthetic,  but  especially  with 


472  ANESTHETICS 

ether  when  the  vapour  is  too  suddenly  applied,  or  increased  in  strength 
too  rapidly  ;  the  treatment  is  obvious,  namely,  withdrawal  or  diminution 
in  strength  of  the  vapour  and  no  further  reference  need  be  made  to  it  here. 
The  irritation  of  the  ether  vapour  may  sometimes  cause  a  good  deal  of 
coughing,  and  if  this  does  not  subside  in  the  course  of  a  few  minutes, 
the  inhalation  of  a  few  drops  (10-20)  of  chloroform  will  often  have  a  good 
effect,  and  the  ether  inhaler  can  subsequently  be  re-applied.  Asphyxial 
symptoms  are  usually  associated  with  marked  lividity  and  gasping  for 
breath,  and  may  be  due  to  a  variety  of  causes,  such  as  the  presence  of 
foreign  bodies  (false  teeth,  detached  nasal  polypi,  etc.),  to  excessive  flow 
of  mucus,  to  blood,  to  extraneous  pressure  upon  the  trachea,  to  falling 
back  of  the  tongue  over  the  glottis  (sometimes  termed  '  swallowing  the 
tongue  '),  etc.  Under  this  head,  too,  may  be  included  those  cases  de- 
scribed by  Lord  Lister,  in  which  the  soft  structures  at  the  back  of  the 
throat  fall  together  like  curtains  in  front  of  the  glottis. 

Respiratory  Paralysis. — Of  course,  under  any  of  the  above  circum- 
stances, the  breathing  tends  to  fail ;  but  when  we  speak  of  '  failure  of 
breathing '  under  anaesthetics,  and  especially  chloroform,  what  is  usually 
meant  is  the  failure  due  to  an  overdose.  The  nervous  system  becoming 
paralysed,  the  medullary  centres  cease  to  act,  and  the  respiratory  move- 
ments, becoming  feebler  and  feebler,  at  length  stop  altogether.  The 
ashy-grey  pallor  and  imperceptible  pulse,  the  entire  cessation  of  breath- 
ing, the  complete  relaxation  of  the  tissues  (extending  sometimes  even 
to  the  sphincters),  the  widely  dilated  pupils,  the  general  aspect  of  the 
patient,  not  unlike  the  fades  hippocratica  of  actual  death,  are  all  very 
characteristic,  and,  in  fact,  may  almost  be  said  to  be  pathognomonic 
of  chloroform  poisoning  ;  sometimes,  the  respiratory  failure  is  almost 
lightning-like  in  rapidity,  but  more  often  it  is  gradual  and  insidious 
in  onset. 

As  is  well  known,  the  clinical  signs  and  symptoms  of  respiratory 
paralysis  closely  resemble,  and  are  frequently  associated  and  coincident 
with  those  due  to  syncope,  and,  on  the  other  hand,  obstruction  to  the 
breathing  sooner  or  later  leads  to  cardiac  failure.  In  practice,  it  is  often 
impossible  to  decide  whether  the  respiratory  or  the  cardio-vascular 
system  was  first  affected,  but  it  is  of  the  utmost  importance  that  the 
administrator  should  be  able  to  appreciate  the  fact,  that  certain  signs 
and  symptoms  are  indicative  of  approaching  danger  from  their  very 
commencement.  Such  early  recognition  of  symptoms  is  only  possible 
when  the  administrator  is  unceasingly  vigilant,  and  single-minded  in  his 
attention  to  his  duties,  and  when  thus  recognised  the  mere  withdrawal 
of  the  anaesthetic  often  suffices  to  correct  the  error,  without  subjecting 
the  patient  to  any  additional  risk. 

It  is  to  the  respiratory  and  the  circulatory  systems,  and  especially  the 
former,  that  the  greatest  attention  should  be  devoted,  and  the  slightest 
alteration  in  either  one  or  the  other  should  be  carefully  noted  and  watched. 


DIFFICULTIES  AND  DANGERS  473 

If  this  be  done,  it  will  soon  be  seen  that  signs  of  danger  may  very  readily 
be  grouped  under  three  heads,  namely : 

(1)  Symptoms  in  which  cardiac  failure  or  syncope  is  the  prominent 

feature.  (Pallor,  pulse  gradually  becoming  imperceptible  ;  pupil 
slowly  dilating;  respirations  unaltered  at  first,  but  gradually 
failing,  though  seldom  abolished  completely.)  Generally  to  be 
looked  for  in  the  earlier  stages  of  anaesthesia  ;  often  the  precursor 
sickness.  As  a  rule,  easily  recoverable. 

(2)  Symptoms  in  which  the  respiratory  failure  is  the  most  prominent 

feature.  (Respirations  early  affected,  feeble,  and  shallow  ;  pallor, 
often  of  the  ashy-grey  type  ;  pulse  fairly  good  at  first,  but  slowly 
failing  ;  pupils  quickly  dilating.)  A  condition  of  the  middle  and 
late  stages,  and  tending  to  merge  into 

(3)  Simultaneous  or  almost  simultaneous,  sudden,  and  complete  cessa- 

tion of  both  circulation  and  respiration,  with  fades  hippocratica, 
suddenly  and  widely  dilated  pupils.  May  occur  early  (syncope) 
or  late  (toxic  overdose).  A  very  serious  condition  ;  when  fully 
developed  in  the  earlier  stages  of  anaesthesia,  it  is  doubtful  if 
recovery  be  possible. 

Treatment — Reference  has  already  been  made  (see  p.  456)  to  the 
treatment  to  be  adopted  when,  in  ether  anaesthesia,  the  muco-sali vary  secre- 
tion becomes  excessive,  and  to  the  treatment  of  spasm  of  the  glottis.  The 
treatment  of  other  forms  of  gross  asphyxia  is  so  perfectly  obvious,  that 
it  may  be  dismissed  in  a  very  few  words.  If,  with  a  patient  sitting  up,  as 
for  nitrous  oxide  anaesthesia,  blood  or  a  foreign  body,  such  as  a  tooth, 
slips  back  into  the  larynx,  the  body  of  the  patient  should  be  bent  sharply 
forward  so  as  to  bring  the  head  over  the  knees  ;  coughing  should  be  en- 
couraged by  smartly  patting  the  back,  and  by  passing  the  finger  into  the 
throat  to  irritate  the  vocal  cords.  This  latter  manoeuvre  may  reveal  the 
presence  of  the  foreign  body  itself,  and  an  attempt  may  be  made  to  remove 
it  by  means  of  the  laryngeal  forceps;  if  this  attempt  do  not  succeed, 
the  advisability  of  performing  tracheotomy,  or  even  better,  laryngo- 
tomy,  must  be  considered.  Of  course,  in  many  cases,  this  operation  would 
be  performed  by  the  operating  surgeon,  but  the  administrator  should 
always  be  provided  with  suitable  instruments,  for  occasion  may  arise,  e.g. 
in  dental  work,  in  which  they  may  be  urgently  called  for  and  when  the 
anaesthetist  may  himself  have  to  operate.  In  any  event,  the  responsi- 
bility rests  with  the  anaesthetist. 

In  respect  to  the  other  symptoms  mentioned  above,  it  must  be  borne 
in  mind  that,  although  in  some  instances  their  development  is  almost 
unavoidable,  yet  in  many  if  not  in  the  majority  of  the  cases  in  which  they 
are  very  pronounced,  they  can  be  traced  to  some  error  of  omission  or  com- 
mission on  the  part  of  the  anaesthetist.  It  may  not,  therefore,  be  out  of 


474  ANESTHETICS 

place  to  recapitulate  what  may  be  termed  the  prophylactic  treatment  in 
respect  to  these  symptoms,  viz. — 

(a)  Take  care  to  remove  beforehand  anything  that  may  obstruct  the 
breathing,  or  that  may  fall  into  the  throat  when  the  parts  are  relaxed 
under  anaesthesia. 

(b)  Excepting  in  the  case  of  nitrous  oxide,  always  induce  anaesthesia 
gradually  ;  this  does  not  of  necessity  mean  slowly,  but  rather  the  gradua- 
tion of  strength  of  the  vapour,  not  increasing  the  strength  beyond  that 
which  can  be  readily  borne. 

(c)  The  administrator  should  devote  the  whole  of  his  attention  to 
the  administration.     He  should  not  be  called  upon  to  hold  instruments, 
or  otherwise   assist    the   surgeon,  or  even  interest  himself  about  the 
operation. 

(d)  As  soon  as  sufficiently  relaxed,  the  head  must  be  turned  to  one 
side,  so  as  to  permit  the  mucus  to  flow  out  of  the  mouth  and  prevent  the 
tongue  falling  backwards. 

(e)  The   respiration  and  especially  the  expiration  must  be  watched 
with  particular    care,  the  hand  being  occasionally  held  in  front  of  the 
nose  and  mouth  to  test  the  force  of  the  breathing.     The  movements 
of  the  chest  and  abdomen  are   not  to  be  relied  upon,  as  they  may  be 
altogether  out  of  proportion  to  the   amount  of   air  actually  entering 
the  lungs.     Nor  is  the  sound  of  the  breathing  to  be  depended  upon  ;  it 
may  be  largely  due  to  mucus,  or  to  buccal  or  palatine  stertor.      In 
my  opinion,  too,  mechanical  indicators  in  the  shape  of  feathers,  etc., 
are  apt  to  be  fallacious.     They  induce   a  false  sense  of  security,  as 
they  do  not  distinguish  between  a  very  light  and  a  moderately  forcible 
expiration.    At  the  same  time  the  circulation,  as  indicated  by  the  colour 
of  the  face  and  ears,  should  be  watched,  and  the  pupil  observed. 

(f)  If  in  doubt  as  to  the  exact  significance  of  any  particular  or  peculiar 
symptom  or  change,  it  is  safer  to  allow  the  patient  to  come  round  rather 
than  press  the  anaesthetic. 

Active  Treatment. — If,  however,  any  of  the  conditions  indicated 
above  have  developed,  the  following  routine  treatment  should  be  adopted. 
It  is  of  importance  that  the  exact  order  of  procedure  be  observed  ;  that 
each  step  be  carried  out  deliberately  and  completely  without  flurry  ;  that 
a  wait  of  at  least  a  few  seconds  be  made  between  each  movement,  to  be 
sure  of  its  effect,  and,  in  extreme  cases,  that  treatment  be  persevered  in 
for  some  time,  even  although  apparently  hopeless. 

(i)  Keep  the  head  turned  to  one  side,  but  do  not  otherwise  alter  the 
position  of  the  patient.  Withdraw  the  anaesthetic.  Extend  the  head 
upon  the  trunk  by  pressing  backwards  upon  the  forehead  ;  release  the 
base  of  the  tongue  by  forcible  pressure  upon  the  lower  law  at  the  angles, 
so  as  to  protrude  the  lower  incisor  teeth  beyond  the  upper,  or  by  pulling 
forward  the  chin  so  as  to  raise  the  hyoid  bone  and  larynx.  It  will  often 
happen  that  in  the  very  earliest  stages  of  respiratory  embarrassment, 


nothing  more  is  required. 
means  the  next  step  is  _ 


DIFFICULTIES  AND  DANGERS  475 

If  the  breathing  be  not  restored  by  th« 


means  °f  the 


which  should 
°f  the 


be  at 


FlG-  *l6-—  MOUTH  GAG. 


<  rgue  foreibiy 

tongue  to  any  appreciable 
extent,  but  mainly  acts 
reflexly,  and  causes  the  re- 
traction of  the  soft  tissues 
in  front  of  the  glottis,  and 
is,  therefore,  of  particular 
service  in  the  condition 
described  by  Lord  Lister 
(see  p.  462). 

(3)  Should  the  above  manoeuvres  have  no  effect,  the  next  proceeding 
is  to  explore  and  clear  out  the  air-  way.  The  finger  is  passed  to  the  back 
of  the  throat,  and  used  as  a  hook  to  draw  forward  the  epiglottis  and  base 
of  the  tongue,  and  this  has  often  a  very  marked  effect,  and  should  on  no 
account  be  neglected.  At  the  same  time,  anything  in  the  shape  of  a  foreign 
body  can  be  felt  for,  and,  if  found,  attempts  may  be  made  to  remove  it 
with  the  finger,  or  by  means  of  the  laryngeal  forceps.  The  throat  must 
be  sponged  to  get  rid  of  the  mucus  and  blood,  and,  if  this  be  excessive,  the 
patient  may  very  gently  be  turned  on  one  side. 


FIG.  217. — TONGUE  FORCEPS. 


If  a  foreign  body  or  definite  obstruction  can  be  felt,  but  cannot  be 
removed  with  the  finger  or  by  means  of  the  forceps,  and  if  the  asphyxia 
is  becoming  more  intense,  the  question  of  tracheotomy  may  now  arise 
but  mere  feeble  breathing,  without  definite  signs  of  obstruction,  is  no 
indication  for  opening  the  trachea. 

It  is  absolutely  essential  to  commence  with  the  above  three  proceedings 
as  preliminary  to  anything  else  that  may  be  done  ;  it  is  useless  to  attempt 
to  force  air  into  the  chest,  by  artificial  respiration  or  other  means,  unless 
we  first  assure  ourselves  that  the  air-passages  are  clear.  Violent 


476  ANESTHETICS 

movement  of  the  patient  at  this  early  stage  may  have  no  other  result 
than  that  of  shaking  the  last  flicker  of  life  out  of  his  body ;  do  not, 
therefore,  be  over-hasty.  If,  after  waiting  for  ten  or  fifteen  seconds,  we 
get  no  response  to  our  efforts,  the  next  steps  are — 

(4)  Make  two  or  three  momentary  pressures  upon  the  sternum ;    it 
may  be  that  it  is  merely  the  rhythm  of  respiration  which  is  in  abeyance. 

(5)  Invert  the  patient.    Children  may  be  held  up  by  the  heels  ;  with 
adults,  an  assistant  standing  on  the  table  may  hold  up  the  legs,  and  the 
body  of  the  patient  may  be  pulled  upwards,  so  that  the  head  hangs  over 
the  end  of  the  bed.     One  theory  explaining  the  action  of  this  proceeding 
is,  that  it  empties  the  blood  from  the  abdominal  viscera  towards  the  heart 
and  brain.     The  effect,  therefore,  is  one  of  mechanical  stimulus,  and,  if 
this  be  so,  one  can  understand  the  advice  which  is  given  not  to  prolong 
the  position  for  more  than  a  few  minutes  at  a  time. 

(6)  In  adults,  even  while  inversion  is  being  tried,  artificial  respiration 
may  be  started,  commencing  slowly  and  gradually.     The  well-known 
Sylvester's  method  is  the  one  usually  adopted.     Standing  at  the  patient's 
head,  a  firm  grasp  is  taken  just  below  the  elbows,  and  the  arms  brought 
outwards  and  upwards  with  a  rotatory  movement,  some  force  being  used 
to  cause  the  forearms  to  cross  above  the  head  ;    expiration    is  brought 
about  by  reversing  the  movement,  pressing  the  arms  firmly  against  the 
chest  walls  so  that  the  forearms  cross  over  the  front  of  the  chest.     In 
Howard's  method,  which  is  a  most  valuable  adjunct  to  the  above,  the 
surgeon  kneels  astride  of  the  patient,  places  his  outspread  palms  over  the 
margins  of  the  ribs,  pushes  up  the  abdominal  viscera  against  the  dia- 
phragm, and  then  allows  them  to  fall  away,  and  so  alternately  diminishes 
and  increases  the  capacity  of  the  thorax.     When  possible,  these  two 
methods  should  be  carried  out  simultaneously,  but  in  any  event   the 
movements  should  not  be  made  roughly  or  too  rapidly  ;  about  sixteen  or 
seventeen  to  the  minute  is  ample.     In  infants,  it  is  useful  to  remember  that 
pressure  on  the  abdomen  upwards  towards  the  diaphragm,  or  upon  the 
costo-diaphragmatic  margin,  is  often  more  effectual  than  anything  else. 

It  has  been  urged  against  these  two  plans  of  artificial  respiration  that 
there  is  a  danger  of  pumping  up  the  contents  of  the  stomach  into  the 
pharynx,  and  so  practically  drowning  the  patient,  and  the  Marshall  Hall 
method  of  turning  the  patient  alternately  upon  his  face  and  side  has  been 
suggested  as  an  alternative.  But  the  objection  can  hardly  apply  unless 
the  movements  have  been  made  altogether  too  violently  and  too  quickly, 
and  mention  is  only  made  of  it  here  in  order  to  emphasise  these  points, 
and  to  put  the  administrator  on  his  guard. 

In  the  majority  of  cases,  if  the  breathing  has  shown  no  signs  of  re- 
commencement after  artificial  respiration  has  been  continued  for  five  or 
ten  minutes,  the  prognosis  is  exceedingly  grave  ;  but  it  is  not  altogether 
hopeless,  so  that,  while  still  persevering  with  the  artificial  respirations, 
some  of  the  following  plans  should  be  adopted  by  the  assistants.  It  must 


AFTER-TREATMENT  477 

be  quite  understood,  however,  that  although  these  plans  are  to  be  carried 
out  concurrently  with  the  artificial  respiration,  and  on  no  account  is  the 
latter  to  be  superseded  by  them. 

(7)  Cold  affusions  in  the  shape  of  douches  or  flipping  the  chest  with 
wet  towels.     Alternate  very  hot  and  cold  sponges  to  the  perineum. 

(8)  Inhalation  of  nitrate  of  amyl  to  alter  the  distribution  of  the  intra- 
vascular  tension.     Strong  ammonia  held  to  the  nose. 

(9)  Electricity.    Either  the  interrupted  (Faradic)  or  the  continuous 
current  may  be  used.     One  pole  is  applied  to  some  neutral  point,  e.g.  the 
nape  of  the  neck,  and  the  other  pole  is  pressed  over  the  cardiac  area, 
along  the  costo-diaphragmatic  margin,  or  along  the  course  of  the  phrenic 
and  pneumogastric  nerves  in  the  neck,  the  current  being  alternately  made 
and  broken. 

(10)  Hypodermic  injections  of  ether  or  brandy   (npcxx)   are  usually 
given,  but  the  proceeding  is  a  little  illogical.    The  patient  is  already 
suffering  from  a  form  of  alcoholic  poisoning,  and,  further,  the  circulation 
is  too  depressed  to  hope  for  absorption.     For  this  latter  reason,  too,  the 
hypodermic  injection  of  drugs,  such  as  digitaline,  is  hopeless  at  this  stage. 

(n)  The  intra-venous  injection  of  normal  salt  solution,  or  rectal  injec- 
tions of  the  same,  appear  to  be  more  rational.  By  altering  the  blood 
pressure  they  may  possibly  stimulate  the  circulation. 

(12)  As  almost  a  last  resource,  aeu-puneture  or  galvano-puncture  of 
the  heart  itself  has  been  recommended.  It  has  even  been  suggested 
that  by  making  a  small  incision  along  the  margins  of  the  left  ribs,  the 
fingers  of  the  hand  can  be  passed  in,  and  direct  pressure  applied  to  the 
heart.  I  have  no  personal  experience  of  these  measures,  but  it  appears 
to  me  that  acu-puncture  and  galvano-puncture  not  only  waste  valuable 
time,  but  are  more  likely  to  do  harm  than  good.  The  plan  of  directly 
pressing  on  the  heart  seems  to  be  better  justified,  theoretically,  but  it  has 
not  been  very  successful  in  the  few  cases  in  which  it  has  been  put  to 
practical  proof. 

Supposing  that  no  response  has  been  obtained  to  these  efforts,  the 
artificial  respiration  should  be  persevered  in  for  at  least  half  an  hour,  and 
of  course,  if  the  slightest  attempt  at  natural  breathing  be  made,  a  longer 
time  should  be  given  to  the  work.  Even  after  a  fairly  regular,  though 
feeble  respiratory  rhythm  has  been  re-established,  the  greatest  care  should 
be  taken  in  moving  the  patient,  as  relapses  are  apt  to  occur ;  he  should 
not  be  left  for  some  hours,  and  should  be  kept  very  warm. 


AFTER-TREATMENT. 

In  conclusion,  a  few  words  may  be  said  as  to  the  after-treatment  of 
patients  recovering  from  an  anaesthetic,  as  this  is  a  point  upon  which  the 
ansesthetist  is  often  consulted.  Practically,  no  after-treatment  is  required 


478  ANESTHETICS 

for  nitrous  oxide ;  the  following  remarks  are  intended  only  for  the 
major  anaesthetics. 

In  dressing  a  case  after  operation,  care  should  be  exercised  that  the 
bandages,  etc.,  do  not  impede  the  breathing.  This  is  particularly  neces- 
sary in  operations  about  the  head  and  neck,  and  it  comes  within  the  pro- 
vince of  the  administrator  to  see  that  no  trouble  arises  from  this  cause.  In 
these  cases  the  bandages  should  be  firmly  applied,  while  the  neck  is  fully 
extended ;  the  pressure  will  not  then  be  too  great  when  the  neck  is 
restored  to  position. 

In  ordinary  cases,  the  patient  may  be  put  back  to  a  warm  bed  before 
he  completely  recovers  consciousness.  In  making  the  transfer,  however, 
care  should  be  taken  not  to  jolt  him,  and  especially  not  to  elevate  the 
head  and  chest ;  in  going  upstairs,  therefore,  he  should  be  carried  on  a 
stretcher,  feet  first,  with  his  head  down.  The  room  should  be  of  a  tem- 
perature of  about  65°-7o°  F.,  and  the  bed  carefully  screened  from  draughts. 
If  ether  has  been  employed,  and  perhaps  in  all  cases,  it  is  better,  if  the 
surgeon  will  permit,  that  the  patient  be  turned  upon  the  right  side  ;  this 
facilitates  the  escape  of  mucus,  and  I  think  lessens  the  sickness.  The 
nurse  should  be  warned  that  if  sickness  occur,  the  patient  is  not  to  sit  up, 
but  to  be  turned  .on  his  side,  and,  if  need  be,  the  jaw  must  be  pushed 
forward  to  facilitate  the  escape  of  the  vomited  matter. 

The  anaesthetist  should  assure  himself  that  his  patient  is  on  the  high 
road  to  recovery  before  he  leaves  the  patient's  side,  but  on  the  other 
hand,  natural  sleep  is  to  be  encouraged ;  if,  when  taken  at  intervals  of 
two  or  three  minutes,  the  pulse  and  respiration  are  found  to  be  good 
and  improving,  it  may  fairly  be  assumed  that,  as  far  as  the  anaesthetic 
is  concerned,  the  patient  is  safe.  In  any  event,  whether  the  case  is 
a  severe  one  or  not,  the  patient  should  always  have  a  responsible 
attendant  at  his  bedside  for  an  hour  or  two  after  the  operation  has  been 
completed. 

Sickness. — As  soon  as  he  is  sufficiently  conscious  to  be  able  to  do 
so,  the  patient  should  be  encouraged  to  rinse  out  his  mouth  and  throat 
frequently  with  warm  water.  If  retching  and  vomiting  occur  early,  in  the 
semi-unconscious  condition,  they  are  less  distressing  to  the  patient  than 
might  be  supposed ;  when  he  becomes  fully  conscious  he  seldom  retains 
any  recollection  of  his  previous  misery.  Nevertheless,  attempts  should  be 
made  to  ameliorate  his  condition.  Sips  of  water  as  hot  as  can  be  borne, 
or  even  full  draughts  of  half  a  tumblerful,  are  often  successful ;  strong, 
hot,  black  coffee  is  good  in  some  cases ;  15-20  grains  of  bicarbonate  of 
soda  in  a  tumblerful  of  hot  water  is  good  in  others ;  ice  to  suck  is  the 
routine  treatment,  and  is  very  comforting  to  the  patient ;  strychnine  in 
5-minim  doses  of  the  liquor  by  the  mouth  or  hypodermically,  has  been 
recommended;  bromide  of  potassium  20  grains  and  chloral  hydrate 
15  grains  dissolved  in  2  ounces  of  water  and  passed  into  the  rectum 
immediately  after  the  operation  is  said  to  act  very  well  in  some  cases  ; 


AFTER-TREATMENT  479 

in  the  more  troublesome  cases  morphine  may  be  called  for,  but  in  the 
majority  of  instances  time  alone  is  all  that  can  be  depended  upon. 

Cases  involving  severe  '  surgical  shock  '  require  additional  care.  In 
such  cases,  the  amount  of  the  anaesthetic  used  in  the  latter  stages  may, 
with  advantage,  be  very  much  diminished,  and  strychnine  hypodermically 
may  be  given  freely  up  to  -fa  grain.  It  is  in  these  cases,  too,  that  the 
hypodermic  injection  of  brandy  or  ether  may  be  of  value,  but  enemata  of 
hot  black  coffee  or  beef-tea  are  probably  better.  Such  patients  should 
not  be  put  back  to  bed  too  soon,  but  be  kept  on  the  operating  table, 
which  should  be  raised  some  four  or  five  inches  from  the  ground  at  one 
end  so  as  to  raise  the  patient's  legs.  Anaesthetised  patients  are  so  very 
apt  to  be  blistered  by  hot  water  bottles  that  I  now  make  it  an  absolute 
rule,  never  to  permit  one  to  be  placed  in  the  bed,  until  after  the  lapse 
of  twenty-four  hours.  If  additional  warmth  be  required,  hot  blankets 
should  be  used. 

If  the  shock  be  the  result  of  loss  of  blood  it  may  be  advisable  to  give 
an  injection  of  normal  salt  solution  into  the  veins,  the  cellular  tissue  of 
the  axilla  or  the  rectum  (see  p.  112)  ;  the  hot  nutrient  enemata  recom- 
mended above  is  also  very  efficacious. 

The  patient  may  recover  perfectly  from  the  immediate  effects  of  the 
anaesthetic,  but  it  occasionally  happens  that,  about  twenty-four  hours 
after,  his  temperature  rises  and  his  pulse  becomes  feeble  and  quick  ; 
there  is  great  restlessness  and  some  delirium,  and  the  patient  dies  coma- 
tose. At  the  post-mortem  the  liver  is  found  to  be  enlarged  and  to  present 
every  indication,  microscopically,  of  acute  fatty  degeneration.  These 
fatalities  are  most  frequent  in  children,  and  after  chloroform,  but  they 
are  also  seen  in  young  adults,  and  after  other  anaesthetics  ;  and  the  con- 
dition known  as  status  lymphaticus  acts  as  a  predisposing  cause.  The 
treatment  of  these  cases  is  unsatisfactory ;  stimulants  and  cardiac  tonic 
such  as  strychnine,  digitaline,  etc.,  are  indicated,  but  when  once  the 
coma  has  set  in,  recovery  is  rare  ;  in  this  as  in  other  respects  they  some- 
what resemble  cases  of  diabetic  coma. 

The  train  of  symptoms  described  above  has  been  the  subject  of 
careful  inquiry  by  Stiles  and  MacDonald.  These  investigators  suggest 
that  the  symptoms  are  due  to  the  toxic  action  of  the  anaesthetic  rather 
than  to  septic  infection,  as  was  at  one  time  supposed,  and  as  the  micro- 
scopic appearances  might  lead  one  to  suspect.  In  accordance  with 
these  recent  views,  the  condition  is  now  known  as  that  of  '  delayed 
chloroform  poisoning,'  and  the  responsibility  for  the  death  is  shifted  from 
the  operation  to  the  anaesthetic.  I  must  confess  that  I  have  practically 
no  experience  of  these  cases. 

Diet. — No  food  should  be  given  by  the  mouth  for  at  least  three  or 
four  hours  after  an  anaesthetic  has  been  administered  (in  the  case  of 
nitrous  oxide,  however,  an  hour's  abstinence  will  suffice),  and  a  further 
wait  of  two  or  three  hours  should  be  made,  unless  the  patient  express  a 


480  LOCAL  ANAESTHESIA 

desire  for  food,  or  if  the  sickness  be  very  persistent.  In  cases  of  collapse, 
marked  emaciation  and  feebleness,  etc.,  nutrient  enemata  should  be  given 
every  two  or  three  hours,  commencing  immediately  before  the  opera- 
tion, rather  than  run  any  risk  of  irritating  the  stomach.  The  first  food 
by  the  mouth  should  take  the  form  of  broth,  beef-tea,  or  soup,  in 
preference  to  milk,  which  is  apt  to  form  a  hard  indigestible  curd 
which  may  irritate  the  stomach  in  its  catarrhal  condition.  When  the 
first  food  has  been  retained,  the  patient  may  return  by  degrees  to  the 
ordinary  diet,  as  far  at  any  rate  as  the  anaesthetic  is  concerned. 

Delirium  and  excitement,  when  they  occur,  must  be  gently  restrained, 
but  the  patient  must  not  be  tied  down.  In  the  case  of  lunatics,  the  feeble- 
minded, and  even  those  with  a  previous  historj7  of  mental  disturbance, 
the  friends  should  be  warned  that  a  recrudescence  of  the  mental  trouble 
occasionally  occurs  after  the  administration  of  any  anaesthetic. 


PART  II. 
LOCAL  ANESTHESIA. 

PRELIMINARY   OBSERVATIONS. 

Whether  pain  be  the  result  of  disease  or  be  caused  by  surgical  inter- 
ference, the  first  and  most  natural  impulse  is  to  seek  relief  in  local  appli- 
cations ;  we  find,  therefore,  that  such  applications  have  been  in  vogue 
from  the  earliest  times.  The  use  of  inhalations  of  the  vapours  of  ether 
and  chloroform  quickly  supplanted  the  less  certain  and  somewhat 
empirical  local  methods  formerly  employed,  and  it  is  only  during  the 
last  ten  or  fifteen  years  that  the  production  of  local  anaesthesia  has  been 
systematically  studied ;  and  it  is  even  more  recently  that  any  attempts 
have  been  made  to  define  its  advantages  and  limitations.  It  is  to  Con- 
tinental and  American  surgeons  that  we  are  chiefly  indebted  for  our 
knowledge  of  the  subject ;  in  this  country,  the  plans  advocated  have 
met  with  but  a  limited  amount  of  support. 

Advantages. — It  is  claimed  for  local  anaesthetics  that  no  previous 
preparation  of  the  patient  is  required  ;  that  they  are,  on  the  whole,  more 
portable  and  more  available  than  most  general  anaesthetics ;  that  they 
are  easy  of  application ;  that  it  is  sometimes  of  advantage  that  the 
patient  should  be  able  to  assist  the  surgeon  in  his  manipulations,  e.g.  by 
forcing  down  a  hernia ;  that  they  can  often  be  used  when  a  general 
anaesthetic  would  be  inadvisable,  e.g.  in  cases  of  collapse,  and  when  the 
patient  has  an  unnatural  dread  of  a  general  anaesthetic  ;  that,  on  the  whole, 
some  of  the  methods  are  safer,  and  are  less  likely  to  be  followed  by  dis- 


PRELIMINARY  OBSERVATIONS  481 

agreeable  after-effects.  Against  this  list  of  advantages  must  be  balanced 
the  objections  that  they  are  uncertain  in  action,  and  cannot  always  be 
relied  upon  to  produce  the  desired  effect,  so  that  it  is  usually  necessary 
to  hold  a  general  anaesthetic  in  reserve,  to  be  used  if  required;  the 
tissues  are  not  always  completely  relaxed ;  the  appearance  of  the  sur- 
rounding parts  is  so  altered  by  the  oedema,  etc.,  that  dissection  becomes 
almost  impossible,  and  it  is  open  to  question  whether  the  healing  of  the 
wound  be  not  retarded  and  the  liability  to  sepsis  increased ;  the  fear  of 
the  operation,  and  the  very  disturbing  element  of  the  sight  of  instruments, 
blood,  etc.,  has  always  to  be  reckoned  with,  even  in  the  apparently 
robust  and  firm-minded. 

Kocher  1  is  of  opinion  that  the  ordinary  methods  of  local  anaesthesia 
are  not  always  so  absolutely  painless  as  its  advocates  maintain,  and  that 
it  sometimes  scares  patients  from  having  a  subsequent  and,  perhaps,  more 
necessary  operation  performed. 

Cases  suitable. — A  careful  study  of  the  lists  which  have  been  pub- 
lished of  operations  which  can  be  and  have  been  performed  by  the  aid 
of  local  anaesthetics,  and  having  regard  to  the  attendant  circumstances 
of  the  cases  recorded,  leads  one  to  the  conclusion  that,  as  far  as  our 
present  knowledge  goes,  the  chief  occasions  on  which  local  can  claim  any 
real  advantage  over  general  anaesthesia  are  as  follows,  viz. : — 

(1)  In  very  brief  cases  where  no  dissection  is  required,  e.g.  simple 

puncture  or  incision  of  small  abscesses,  and  when  nitrous  oxide 
is  not  available  or  is  objected  to. 

(2)  In  the  aged,  whose  whole  nervous  system  and  tissues  generally 

are  often  less  sensitive  than  in  younger  people. 

(3)  In  those  who  are  much  collapsed,  or  feeble  and  emaciated,  and 

in  whom,  therefore,  there  is  reason  to  fear  the  effect  of  a  general 
anaesthetic  in  depressing  the  already  reduced  vitality. 

(4)  In  opthalmic  surgery,  in  acute  lung  troubles,  and  in  some  opera- 

tions involving  the  superficial  mucous  membranes,  e.g.  nasal 
polypi. 

Although  special  preparation  of  the  patient  is  not  so  imperatively  called 
for  as  with  general  anaesthesia,  it  is,  nevertheless,  of  advantage  that  the 
general  condition  should  be  improved  by  careful  regulation  of  the  diet, 
etc.,  for  a  few  days  beforehand.  Purging  or  starving  are  not,  of  course, 
at  all  necessary  ;  in  fact,  it  is  better  that  the  patient  should  have  a  cup 
of  hot  broth  or  beef-tea  immediately  before  the  operation ;  this  may 
counteract  any  tendency  to  syncope,  and  for  the  same  reason  a  li 
stimulant  is  not  objectionable.  Whenever  possible,  the  patient  should 
be  recumbent. 

Methods.— The  local  methods  most  in  use  at  the  present 

1  Kocher.  Operative  Surgery,  3rd  English  edition,  p.  17. 

II 


482  LOCAL  ANESTHESIA 

may  be  considered   under   the  following   heads,  viz.  :    (i)    Freezing ; 

(2)  Drugs,  either  applied  to  the  surface  or  injected  into  the  tissues ; 

(3)  Spinal  injections. 

FREEZING. 

The  anaesthetic  properties  of  intense  cold  have  long  been  made  use 
of  in  practical  surgery.  In  operative  work,  the  cases  most  suitable  for 
freezing  are  those  which  do  not  involve  any  large  area  of  surface,  but 
which  only  require  a  short,  simple  incision  or  puncture,  e.g.  opening  a 
superficial  abscess.  The  method  is  open  to  the  special  objections  that 
the  tissues  are  apt  to  become  so  hard,  that  it  is  sometimes  difficult  to  cut 
through  them,  so  no  dissecting  operation  can  be  carried  out ;  and  that 
the  process  of  thawing  is  often  accompanied  by  much  pain,  the  healing  is 
retarded,  and  the  tissues  are  liable  to  slough. 

The  late  Sir  Benjamin  Ward  Richardson  was  a  great  advocate  for 
freezing  anaesthesia,  and  introduced  the  ether  spray. 


FIG.  218. — METAL  BOTTLE  CONTAINING  AN^ESTILE. 

The  most  convenient  adaption  of  this  principle  of  freezing  by  evapora- 
tion is  seen  in  the  use  of  tubes  containing  ethyl  chloride,  ansestile,  and 
other  fluids  of  low  boiling  point  (Fig.  218).  In  these  tubes,  the  heat 
of  the  hand  suffices  to  drive  a  stream  of  the  liquid  through  a  minute 
hole  in  the  nozzle,  and  at  a  distance  of  a  few  inches  the  jet  is  broken 
up  into  a  fine  spray,  and,  the  part  upon  which  this  spray  falls,  is  quickly 
frozen.  These  substances  appear  to  be  rather  more  rapid  in  action  than 
pure  ether,  to  produce  a  sufficient,  but  not  too  great  a  fall  in  temperature, 
and,  therefore,  the  hardness  of  the  skin,  and  the  after-smarting  are  less 
obvious  objections  than  when  simple  freezing,  or  the  ether  spray  are 
employed.  In  using  these  tubes,  care  must  be  taken  that  the  nozzle  is 
held  far  enough  off  the  part  to  enable  the  stream  of  fluid  to  fall  in  a  fine 
shower  upon  the  surface,  otherwise,  free  evaporation  does  not  take  place 
and  the  freezing  is  much  delayed. 

DRUGS  APPLIED  TO  THE  SURFACE. 

Many  drugs,  partly  by  their  direct  action  upon  the  nerve  endings, 
partly  by  the  pressure  of  the  fluid  injected,  partly  by  interfering  with  the 
blood  supply  of  the  part,  have  an  anaesthetic  action  upon  the  tissues  in 
the  immediate  vicinity  of  their  point  of  application.  For  instance,  an 


DRUGS  APPLIED  TO  THE  SURFACE 


483 


incision  made  into  a  tissue  upon  which  pure  carbolic  acid,  or  even  a 
solution  of  i  in  20,  has  been  painted,  will  hardly  be  felt,  but  this  plan  is  not 
to  be  recommended.  The  drug  generally  employed  is  cocaine  or  one  of  its 
derivatives,  such  as  eucaine.  Cocaine  is  the  crystalline,  active  principle 
of  the  leaves  of  the  coca  plant  (erythroxylon  coca),  and  its  chemical  formula 
is  C17H21NO4.  The  alkaloid  itself  is  nearly  insoluble  in  water,  but  the 
hydrochlorate  is  freely  soluble,  and  is  the  form  in  which  the  substance 
is  generally  used.  Solutions  of  this  salt  are  particularly  prone  to  decom- 
position, and  numerous  forms  of  infective  bacteria  frequently  appear. 
To  a  considerable  extent,  this  is  prevented  if  5  per  cent,  of  salicylic  acid 
be  added  to  the  solution. 

When  first  introduced  into  surgical  practice,  the  use  of  5  per 
cent,  and  10  per  cent,  solutions  was  advised,  and  these  are  about  the 
strengths  still  usually  employed  in  this  country.  On  the  Continent 
and  in  America,  however,  where,  as  already  mentioned,  the  subject  of 
local  anaesthesia  has  received  much  attention,  rather  larger  quanti- 
ties of  much  weaker  strength  (i  or  2  per  cent.)  are  used,  so  as  to  avoid 
the  untoward  symptoms  which  frequently  occur  when  the  more  potent 
solutions  are  employed.  In  any  event,  not  more  than  from  J  to 
|  grain  of  the  drug  itself  should  be  injected  hypodermically  at  a  single 
sitting. 

In  using  cocaine,  it  is  particularly  advisable  that,  whenever  possible, 
the  patient  should  be  recumbent,  and,  as  a  useful  precaution,  a  cup  of 
broth  or  beef-tea,  or  an  alcoholic  stimulant,  may  be  given  beforehand. 

The  following  are  the  princi- 
pal plans  adopted,  viz. : — 

(1)  Instillation. — In    ophthal- 

mic surgery  a  few  drops 
of  the  solution  are  placed 
in  the  eye,  and  the  in- 
stillation is  repeated  at 
intervals  of  three  or  four 
minutes,  until  a  suffi- 
cient degree  of  anaesthe- 
sia has  been  obtained ; 
this  is  usually  after  the 
lapse  of  from  five  to  ten 
minutes. 

(2)  Spray. — This  is  useful  in 

operations      about     the 

nose     and    larynx.       A 

convenient       form       of 

spray-producer  is  shown 

in  Fig.  219.      A  few  drops  are  sprayed  at  intervals  over  the 

surface  to  be  operated  upon,  as  with  instillations. 


FIG.  219.— COCAINE  SPRAY  FOR  THROAT  AMD 
WORK. 


I  I  2 


484  LOCAL  ANESTHESIA 

(3)  Painted  on  the  surface,  e.g.  mucous  membranes,  etc.  Or  a 
pledget  of  cotton  wool  soaked  in  the  solution  may  be  allowed  to 
remain  for  a  few  minutes  in  contact  with  the  area  of  operation. 
This  latter  plan  is  useful  in  operations  about  the  anterior  nares 
and  aural  meatus,  but  mere  painting  on  the  unbroken  skin  is 
of  but  little  service. 

Dangers. — Many  people  are  particularly  susceptible  to  the  action 
of  cocaine  ;  even  a  few  minims  sprayed  upon  the  throat  may  give  rise 
to  a  train  of  symptoms  of  a  really  alarming  character,  such  as  vertigo, 
dryness  of  the  mouth,  dilated  pupils,  cold  extremities,  palpitation,  slow 
pulse  of  high  tension,  restlessness  and  delirium,  and  several  fatal  cases 
have  been  recorded.  In  using  cocaine,  therefore,  it  is  particularly 
advisable  that,  whenever  possible,  the  patient  should  be  recumbent, 
and,  as  a  precaution,  a  cup  of  hot,  strong  beef-tea,  or  an  alcoholic  stimulant 
may  be  given  beforehand.  Should  alarming  symptoms  develop,  the 
patient  must  immediately  be  placed  recumbent,  hot  bottles  applied  to 
the  extremities,  stimulants  given,  and  other  precautions  taken  to  avoid 
collapse.  Amyl  nitrite  given  in  the  usual  way  is  said  to  be  a  very  efficient 
antidote.  It  is  claimed  by  some  that  these  poisonous  effects  may  be 
avoided  if  antipyrin  be  added  in  the  proportion  of  8  grains  to  each  grain 
of  cocaine  contained  in  the  solution.  Nowadays  it  is  the  custom  to  add 
a  few  drops  of  the  I  in  1000  solution  of  adrenalin  (an  extract  of  the  supra- 
renal body)  to  the  cocaine  solution,  and  this  is  said  not  only  to  increase 
the  safety  of  the  drug,  but  also  to  render  the  tissues  more  anaemic. 


DRUGS  INJECTED  INTO  THE  TISSUES. 

Of  late  years  certain  allied  synthetic  compounds  or  derivatives  of 
cocaine  have  been  introduced,  and  appear  likely  to  supplant  cocaine  for 
many  purposes,  especially  for  injections  into  the  tissues.  The  best 
known  of  these  are :  Tropoeaine,  dose  i  or  2  c.c.  of  a  5  per  cent,  solution  ; 
derived  from  Java  Coca  ;  Eueaine,  dose  up  to  6  grains  see  below ;  Novo- 
eaine,  dose  from  -1-  to  i  grain  ;  Stovaine,  dose  from  J  to  f  grain  ; 
Alypin,  dose  ^  to  £  grain.  While  equally  efficacious,  these  bodies  appear 
to  be  far  less  likely  to  give  rise  to  toxic  symptoms  than  cocaine  itself. 
It  is  customary,  however,  to  add  a  small  amount  of  Adrenalin  to  the 
solutions  as  indicated  above. 

In  any  plan  that  may  be  employed,  it  is  of  the  utmost  importance 
that  both  the  solutions  and  the  instruments,  used  for  the  purpose,  should 
be  absolutely  sterile.  The  solutions  should  be  made  with  isotonic  salt 
solution,  and  the  sites  of  the  injections,  the  anaesthetist's  hands,  etc.,  as 
thoroughly  washed  and  purified  as  for  a  major  operation. 

Apart  from  lumbar  injections  (which  will  be  dealt  with  separately), 
the  following  are  the  principal  plans  adopted. 


DRUGS  INJECTED  INTO  THE  TISSUES  485 

HYPODERMIC  INJECTIONS. 

In  this  process  the  procedure  is  sufficiently  simple.  The  solution  is 
injected,  a  few  drops  at  a  time,  over  the  whole  area  of  the  operation ; 
when  necessary  some  of  the  injections  are  carried  beyond  the  skin  into 
the  muscles  or  other  deeper  tissues.  Care  must  be  taken  that  the 
maximum  dose  of  the  constituent  drug  is  not  exceeded,  the  solution 
being  diluted  to  the  required  strength. 

The  pain  of  the  punctures  may  be  overcome  by  freezing  the  surface 
with  a  spray  of  anaestile,  or  by  making  the  first  prick  endermicaUy  and 
extending  the  subsequent  punctures  deeper  and  deeper  from  the  margins 
of  the  wheal  thus  raised. 

Infiltration. — In  this  process  reliance  is  placed  upon  the  quantity  of 
fluid  injected  rather  than  upon  any  specific  action  of  the  minute  quantities 
of  the  drugs  that  it  may  contain.  Schleich,  who  introduced  the  plan, 
adds  from  i£  to  30  grains  of  cocaine  to  a  quart  of  water,  but  Kocher 
considers  even  this  small  quantity  unnecessary. 

The  technique  is  practically  the  same  as  in  the  hypodermic  process, 
except  that  the  injections  are  carried  out  much  more  systematically,  and 
the  tissues  below  and  all  round  the  operation  area  are  thoroughly  flooded 
with  the  solution,  from  i  to  15  ounces  being  used.i  The  great  oedema 
produced  by  this  plan  is  thought  by  some,  who  have  tried,  it  to  be  very 
objectionable  in  itself,  and  also  to  retard  the  healing  process  (Kocher 
op.  cit.). 

CONDUCTION  ANESTHESIA. 

In  this  process  the  injections  are  made  either  into  (endoneural)  or 
round  (perineural)  the  principal  nerve  trunks  supplying  the  area 
of  operation  ;  these  may  or  may  not  be  at  some  distance  away  from 
the  site  of  the  incisions.  The  anaesthesia  is  rendered  more  effective 
and  prolonged  if  a  constricting  band  is  placed  round  the  limb  above 
the  point  at  which  the  search  for  the  nerve  is  about  to  be  made. 
The  search  for  the  nerve  trunk  may  be  made  under  the  influence  of  an 
hypodermic  injection,  and  if,  to  the  latter,  an  addition  of  from  I  to  3 
drops  of  the  adrenalin  solution  be  made,  it  will  act  almost  as  well  as  a 
constricting  band.  In  regions  of  the  body  where  the  sensory  nerves 
have  already  taken  a  subcutaneous  course,  e.g.  the  hand  or  foot,  it  may 
suffice  to  make  a  circular  or  semi-circular  band  of  subcutaneous  injections 
a  little  way  above  the  part. 

1  Barker,  who  in  this  country  has  employed  this  method  systematically,  uses 
Eucaine  3  grains,  Sod.  Chlor.  12  grains  in  3J  ounces  boiled  water.     Half  the  quantity 
may  be  injected,  and  by  the  addition  of  Tl\io  of  adrenalin  (i  in  1000)  the  toxi 
of  the  eucaine  is  restrained  and  as  much  as  7  ounces  of  the  solution  can  be  used  in  m 
operations.     British  Medical  Journal,  ii.,  1904,  P-  1683  :  and  Practitioner,  Septe 
ber  1907,  p.  329. 


486  LOCAL  ANESTHESIA 

Kocher  thinks  very  highly  of  this  process,  which  he  believes  will 
come  more  into  vogue  when  the  anatomists  have  supplied  us  with  more 
accurate  maps  of  the  nerve  distributions  of  the  body ;  as  far  as  the 
cutaneous  nerves  are  concerned  this  appears  to  have  been  done  to  his 
satisfaction  by  Spalteholtz,  whose  illustrations  Kocher  reproduces.1 

Venous  Ancesthesia. — In  this  process,  introduced  by  Bier  in  1908  and 
applicable  only  to  the  extremities,  the  area  of  operation  is  rendered  as 
bloodless  as  possible  by  elevation  of  the  limb,  the  use  of  elastic  bandages, 
and  the  firm  application  of  the  tourniquet.  A  superficial  vein  is  then 
opened  and  a  canula  tied  in.  From  100  to  200  c.c.  of  a  0'5  per  cent, 
solution  of  novacaine  are  forced  into  the  vein  and  allowed  to  diffuse  over 
the  site  of  the  operation.  Complete  anaesthesia  appears  in  about  fifteen 
minutes  and  should  last  until  the  tourniquet  is  removed.  The  proceed- 
ing is  a  complicated  and  difficult  one,  and  the  results  obtained  in  this 
country  2  can  hardly  be  considered  satisfactory. 

SPINAL  ANAESTHESIA. 

In  1899  Professor  Bier,  of  Berlin,  demonstrated  the  possibility  3 
of  producing  anaesthesia  of  the  lower  extremities  by  the  injection  of 
cocaine  into  the  sheath  of  the  spinal  cord  in  the  lower  lumbar  region. 
Since  that  date  the  method  has  been  employed  with  increasing  frequency, 
and  may  now  be  considered  to  have  obtained  a  recognised  position  in 
anaesthetics.  The  use  of  cocaine  itself  for  lumbar  puncture  has  been 
practically  abandoned,  its  place  being  taken  by  one  of  the  allied  com- 
pounds referred  to  on  p.  484,  the  technique  of  the  proceeding  being  the 
same  in  any  case. 

Cases  suitable. — Theoretically,  this  method  is  applicable  in  all 
operations  below  the  level  of  the  umbilicus,  and  Jonnesco,  of  Bucharest, 
maintains  that,  by  the  addition  of  small  quantities  of  strychnine  to  the 
solutions,  he  is  able  to  obtain  a  perfectly  safe  and  satisfactory  anaglesia, 
even,  as  high  as  the  vertex,*  but  I  hardly  think  that  he  has  succeeded  in 
convincing  English  anaesthetists  and  surgeons  on  this  point. 

In  the  present  imperfect  state  of  our  knowledge  as  to  the  ultimate 
after-effects  of  these  injections,  it  is  better,  perhaps,  that  they  should 
only  be  used  when  it  is  considered,  that  they  possess  distinct  advantages 
over  the  ordinary  methods  of  general  anaesthesia ;  as,  for  instance,  in  such 
types  as  the  following,  viz :  (i)  Severe  injuries  to  the  lower  extremities, 
whether  an  operation  is  contemplated  or  not,  the  puncture  being  made  as 
soon  after  the  accident  as  possible.  Much  weight  is  to  be  attached  to  the 
view  that '  shock  '  is  thereby  greatly  diminished.  (2)  In  operations  upon 

1  Kocher,  Operative  Surgery,  op.  cit.  p.  18. 

2  Page  and  MacDonald,  Lancet,  October  16,  1909,  p.  1135. 

3  Deutsche  Zeitschrift  f.  Chirurgie,  Bd.  52,  September  1899. 

4  British  Medical  Journal,  November  13,  1909. 


DRUGS  INJECTED  INTO  THE  TISSUES 


487 


the  lower  extremities  (especially  when  the  bones  are  fractured),  which  are 
likely  to  last  for  upwards  of  half-an-hour  in  adult  males  of  the  phlegmatic 
or  robust  type.  The  muscular  relaxation  is  superior  to  that  obtained 
with  ether,  etc.  (3)  When  the  physical  condition  of  the  patient  contra- 
indicates  the  employment  of  a  general  anaesthetic,  e.g.  severe  pulmonary 
and  cardiac  disease,  etc.  (4)  In  elderly  people  with  degenerate  arteries, 
e.g.  diabetic  gangrene. 

On  the  other  hand,  I  am  doubtful  whether  one  is  justified  in  urging  the 
adoption  of  this  plan  upon  women  (at  any  rate  not  in  operations  above  the 
knee),  children,  the  highly  neurotic,  or  for  trivial  operations. 

It  is  one  of  the  advantages  of  this  method  that  but  little  preparation 
of  the  patient  is  called  for.  In  these  as  in  other  cases  it  is,  perhaps,  better 
that  the  patient  should  have  a  few  days'  rest  prior  to  the  operation,  but 
there  is  not  the  same  urgency  as  regards  the  limitation  of  the  diet. 


FIG    220— SYRINGE  AND  NEEDLES  FOR  SPINAL  ANESTHESIA.    A,  Hollow  needle 
with  solid  stillette;  B,  Syringe;  C,  Hollow  stillette. 

Apparatus  and  Procedure— My  own  experience  is  almost  entirely 
limited  to  stovaine  prepared  after  Barker's  formula  (stovaine  0-05  gin., 
glucose  0-05  gm.  to   water  i  c.c.),  supplied   by  Billon   of   Paris 
capsules  containing  2  c.c.  of  the  sterilised  solution.    A  special  synnge 
is    required    of    at    least  2  c.c.   capacity,   and  capable  of    prolong* 
boiling     The  needle  should  be  fairly  stout  and  about  8}  cm.  long, 
and  kept  well  sharpened;  it  should  be  fitted  with  a  solid  stillette  and 
it  is    perhaps,  of  advantage  to  have  in  addition  a  hollow  stillette, 
which  can  be  fitted  to  the  syringe  and  thrust  through 
just  beyond  the  tip  of  the  puncture  needle  when  the  latter  i 
Fig  220).    The  procedure  is  as  follows  :    The  hands  of  the  anaesthetist 
are  thoroughly  disinfected,  and  the  syringe,  etc,  well  boiled. 
is  said  to  be  absolutely  neutralised  by  the  faintest  trace  of  alkali  so  soda 
must  not  be  used  in  boiling  the  instruments,  and  all 1  soap  mus 
pletely  rinsed  off  the  hands.    The  hollow  stillette  is  fitted  to  tl 
and  the  tip  of  a  capsule  being  broken  off  the  whole  of  its  contents  are 


488  LOCAL  ANESTHESIA 

drawn  up  into  the  syringe.  The  patient  is  placed  upon  the  operating 
table,  and  is  either  raised  to  the  sitting  position,  or  is  turned  upon  the 
same  side  of  the  body  as  the  site  of  operation  ;  in  either  case  the  head 
must  be  thrust  well  downwards  towards  the  knees,  so  as  to  open  out  the 
lumbar  interspaces  as  much  as  possible.  The  skin  over  the  lower  lumbar 
region  and  the  hands  of  the  anaesthetist  are  washed  and  disinfected  as 
for  an  operation. 

The  puncture  is  usually  made  in  the  third  interspace  (i.e.  between 
the  third  and  fourth  vertebrae),  which  may  be  best  located  by  taking  an 
imaginary  line  between  the  crests  of  the  ilia  ;  this  line  will  fall  across 
the  spine  of  the  fourth  lumbar  vertebra,  and  the  third  space  is  above. 
The  second  or  even  the  first  interspace  may  be  chosen,  but  in  the  fourth 
space  the  theca  is  apt  to  evade  the  needle. 

The  spot  selected  may  be  first  frozen  with  a  spray  of  ansestile.  The 
needle,  containing  the  solid  stillette  and  held  strictly  horizontally,  is  passed 
through  the  skin  in  the  middle  line  immediately  above  the  spine  of  the 
fourth  vertebra.  After  the  first  plunge  through  the  skin,  the  needle  is 
advanced  more  cautiously,  and  at  a  depth  of  from  2  to  2.\  ins.  can  be  felt  to 
enter  the  spinal  canal,  when  the  stillette  may  be  withdrawn.  Frequently, 
however,  the  needle  impinges  upon  bone,  when  it  must  be  drawn  back 
about  \  in.,  its  direction  altered  and  the  entrance  into  the  canal  carefully 
sought  for.  A  further  advance  of  the  needle  by  from  £  to  \  in.  should 
result  in  the  perforation  of  the  theca  and  the  escape  of  the  cerebro-spinal 
fluid.  It  is  important  that  this  fluid  should  escape  freely  and  the  needle 
should  be  rotated  upon  its  axis  to  ensure  this  ;  usually  from  5  to  10  c.c. 
are  collected  in  a  test  tube,  but  this  is  not  essential.  In  the  passage  of 
the  needle  a  vein  is  sometimes  punctured  and  free  blood  comes  out,  but  this 
usually  disappears  on  pushing  the  needle  forward  ;  or  the  first  few  drops 
of  the  fluid  may  be  mingled  with  blood,  but  this  is  of  little  importance. 

The  fluid  having  run  clear,  the  hollow  stillette  to  which  the  syringe 
containing  the  solution  has  been  attached,  is  passed  through  the  puncture 
needle,  and  the  stovaine  slowly  injected,  care,  of  course,  being  taken  to 
avoid  the  introduction  of  air  bubbles.  For  adults,  I  usually  inject  the 
whole  2  c.c. ,  corresponding  to  f  grain  of  stovaine  ;  but  for  children,  of 
course,  much  less  is  required. 

After  the  injection,  both  shoulders  and  legs  are  slightly  raised.  Motor 
paresis  is  the  first  to  develop,  and  the  anaesthesia  should  be  complete  in 
from  three  to  eight  minutes.  The  anaesthesia  has  been  known  to  extend 
as  high  as  the  clavicle,  but  more  often  it  does  not  reach  higher  than  mid- 
way between  the  umbilicus  and  the  ensiform  cartilage.  Sensation  com- 
mences to  return  after  about  an  hour,  but  is  not  completely  restored  for 
some  hours. 

Difficulties  and  After-effects. — Apart  from  the  intricacies  of  the 
passage  into  the  spinal  canal,  the  chief  difficulties  and  dangers  connected 
with  this  method  are  : — 


DRUGS  INJECTED  INTO  THE  TISSUES  489 

(1)  Total  or  partial  failure  to  produce  the  requisite  degree  of  anas- 
thesia.     These  failures  are  mostly  due  to  imperfect  perforation  of  the 
theca  ;  this  may  be  owing  to  the  puncture  being  made  too  low  down,  or 
to  the  needle  being  blunt,  or  held  at  too  great  an  angle,  the  theca  being 
then  pushed  to  one  side,  or  only  a  valvular  opening  made  ;  in  these  cases 
the  stovaine  solution  escapes  by  the  side  of  the  theca  itself.    Or  the 
solution  may  have  become  mixed  with  an  alkali.    Although  these  explan- 
ations suffice  to  explain  many  failures,  there  are,  in  my  experience,  a  few 
others,  which  can  only  be  accounted  for  on  the  grounds  that  the  patient 
has  some  peculiar  idiosyncrasy. 

It  is  generally  recommended  that,  in  case  of  failure,  a  second  injection 
of  half  a  dose  should  be  made,  and  I  have  not  seen  any  ill-effects  follow 
this  plan.  Of  course,  it  causes  the  patient  some  additional  suffering. 

(2)  Although  syncope  and  partial  collapse  are  generally  due  almost 
entirely  fright,  the  possibility  of  the  occurrence  of  these  symptoms  must 
be  borne  in  mind  before  deciding  upon  employing  this  method  in  the 
neurotic. 

(3)  Of  the  immediate  after-effects  the  most  important  are,  headache, 
abdominal  pain  and  retention  of  urine.    The  latter  may  require  the 
catheter  ;  the  other  symptoms  are  transient  and  usually  yield  readily  to 
full  (15 -grain)  doses  of  aspirin.     More  remotely,  paralytic  affections  of  the 
occular  nerves,  various  spinal  paralyses,  mental  disturbances,  gangrene 
of  the  extremities  and  not  a  few  fatalities  have  all  been  ascribed  to  the  use 
of  this  method ;  but  in  the  present  state  of  our  knowledge  it  would  be 
unwise  to  attach  too  great  weight  to  what  may,  after  all,  prove  to  be 
merely  a  matter  of  coincidence ;   it  is  perfectly  certain,  moreover,  that 
many  thousand  cases  have  been  subjected  to  this  process  with  the  greatest 
advantage  and  without  the  development  of  any  untoward  symptoms 
whatever. 


THE   EXAMINATION   OF  THE   BLOOD   IN 
SURGICAL  CONDITIONS. 

BY  W.  D'ESTE  EMERY,  M.D.,  B.Sc.  (LoND.), 

Pathologist  to  King's  College  Hospital  and  The  Children's  Hospital, 
Paddington  Green. 

IN  a  comparatively  small  number  of  cases  an  examination  of  the  blood 
enables  a  certain  diagnosis  to  be  made  without  further  clinical  investiga- 
tion ;  in  the  greater  number  it  is  only  of  use  as  an  indication  of  the  more 
probable  of  two  diseases,  and  in  these  the  interpretation  of  the  results 
which  are  obtained  is  often  a  matter  of  considerable  difficulty  and  uncer- 
tainty. In  this  short  outline  of  the  subject  reference  will  be  made  chiefly 
to  those  methods  of  investigation  which  are  simple  to  apply,  and  they 
will  be  described  in  connection  with  diseases  in  which  these  indications  are 
useful  and  fairly  conclusive.  For  the  more  difficult  methods  of  blood 
examination,  and  for  the  condition  of  the  blood  in  diseases  other  than  those 
dealt  with  here,  one  of  the  larger  works  on  the  subject  must  be  consulted. 

THE  ENUMERATION  OF  THE  LEUCOCYTES. 

This  is  a  simple  and  easy  proceeding,  and  often  yields  results  of  con- 
siderable value.  The  requisites  are :  A  Thoma's  haemocytometer,  a 
microscope  with  a  £th  in.  lens,  and,  preferably,  a  mechanical  stage,  and  a 
bottle  of  diluting  fluid.  Of  the  latter  there  are  several  in  use,  but  Toison's 
fluid  is  as  good  as  any.  It  consists  of : 

Sodii  Sulph.  ......       8     grammes  (122  grains). 

Sodii  Chlor.    ......       I     gramme  (15  grains). 

Glycerin         .          .          .          .          .          -30     c.c.  (i  oz.). 

Aquae  ......    160     c.c.  (5^  oz.). 

Methyl  violet  .  .  .a  trace. 

(The  English  equivalents  are  approximate  only.) 

It  keeps  well,  but  it  is  advisable  to  filter  it  before  use.  If  this  fluid  is 
not  at  hand  normal  saline  solution  will  answer  very  well,  though  it  is  less 

490 


THE  ENUMERATION  OF  THE  LEUCOCYTES 


491 


easy  to  distinguish  the  leucocytes  if  they  are  unstained,  and  it  is  pre- 
ferable to  use  a  rather  strong  saline  solution  (10  grains  to  5j,  or  there- 
abouts) by  which  means  the  red  corpuscles  become  crenated  and  are 
readily  distinguished  from  the  leucocytes.  The  use  of  solutions  which 
dissolve  the  red  corpuscles  is  not  so  convenient,  and  will  not  be  described. 

Thoma's  hcemocytometer  consists  of  a  pipette  (S)  and  a  counting 
chamber  (a).  The  former  has  a  glass  capillary  tube  (with  graduations  on 
it)  which  dilates  into  a  bulb  (E)  containing  a  glass  ball  to  act  as  a  stirrer. 

Above  this  again  there  is  a  short  length  of  capillary  tubing  with  a 
transverse  mark  with  the  figure  101  above  it.  The  longer  capillary 


0100mm. 


o 


C.Zeiss 
Jena. 


a 


FIG.  221.— THOMA'S  H.SMOCYTOMETKR. 

tube  is  divided  into  tenths,  and  the  division  nearest  the  bulb  (which  is"  the 
only  one  which  need  be  taken  into  account  in  the  present  examination 
is  marked  i.    The  volumes  of  the  various  parts  of  the  instrument  are  s 
proportioned  that  if  blood  be  sucked  up  the  longer  capillary  to  this  mark 
and  the  diluting  fluid  to  the  mark  101  above  the  bulb,  the  bulb  itself  will 
contain  blood  diluted  100  times. 

The  counting  chamber  consists  of  a  plate-glass  slide  (0),  to  the  centr< 
which  a  small  glass  disc  (B)  is  cemented.    Around  this  disc,  but  separate 
from  it  by  a  narrow  space  or  «  moat '  (r),  there  is  a  square  plate  of  glass 
which  is  exactly  ^th  of  a  millimetre  deeper  than  the  central  disc  (I 
thus  if  a  drop  of  fluid  be  placed  on  the  central  disc  and  a  perf 
cover-glass  (D)  be  placed  in  absolute  contact  with  the  outer  square  nng  it 
will  squeeze  the  drop  of  fluid  into  a  perfectly  uniform  layer  ^  « 
depth     The  central  disc  (a  part  of  which  is  shown  more  highly  magn 


492  EXAMINATION  OF  THE  BLOOD 

at  c)  is  crossed  by  two  series  of  very  fine  rulings.  These  are  at  right  angles, 
and  exactly  5^  mm.  apart.  (Certain  of  the  squares  have  a  double  ruling, 
which  need  not  be  considered  here.)  The  area  of  each  square  is,  there- 
fore, ^  X  -^  =  I^TT  of  a  square  millimetre,  and  the  volume  contained 
between  it  and  the  cover-glass  is  ^  X  ^  X  -fa  =  IFOU  °f  a  cubic 
millimetre. 

The  method  is  as  follows.  Rub  the  patient's  ear  so  as  to  make  it 
hyperaemic,  and  draw  a  small  drop  of  blood  by  making  a  short  sharp  prick 
with  a  needle  :  a  Hagedorn's  needle  is  by  far  the  best  to  use  for  this  pur- 
pose, as  plenty  of  blood  can  be  obtained  from  a  prick  which  is  entirely 
painless.  Allow  a  drop  of  blood  to  ooze  out,  and  place  the  tip  of  the 
haemocytometer  therein.  Apply  suction  through  the  india-rubber  tube 
(M)  provided  for  the  purpose,  and  draw  up  a  column  of  fluid  exactly  up 
to  the  mark  i  just  below  the  bulb.  Withdraw  the  pipette,  wipe  off  all 
blood  from  the  end,  insert  the  tip  into  the  Toison's  solution,  and  suck  up 
the  latter  (gently  revolving  the  pipette  as  you  do  so)  until  the  mark  101 
is  reached.  Remove  the  tip  of  the  pipette  from  the  Toison's  solution, 
close  it  by  pressing  it  against  the  pulp  of  your  forefinger,  and  shake  gently 
for  two  or  three  minutes  :  the  glass  ball  will  act  as  a  plunger,  and  the 
blood  and  fluid  will  be  thoroughly  mixed.  If  you  are  not  making  the 
examination  at  the  patient's  bedside  a  stout  india-rubber  band  may  now 
be  stretched  over  the  pipette,  so  as  to  close  both  orifices.  It  is,  however, 
not  advisable  to  defer  the  examination  more  than  an  hour  or  so,  as 
very  serious  errors  may  creep  in,  the  usual  result  being  that  the  count 
is  decidedly  lowered,  probably  partly  from  adhesion  of  the  leucocytes  to 
the  glass,  and  partly  from  the  formation  of  clumps.  If  any  length  of 
time  has  elapsed  between  collecting  the  blood  and  making  the  examina- 
tion the  pipette  must  be  well  shaken  immediately  before  the  preparation 
is  made. 

Now  clean  the  counting  chamber  thoroughly  with  water  (never  use 
alcohol,  xylol,  etc.,  for  this  purpose)  and  polish  it  with  a  clean,  dry 
handkerchief,  and  treat  the  special  thick  cover-glass  provided  with  the 
apparatus  in  the  same  way.  Blow  out  about  half  the  mixture  from  the 
bulb,  wipe  the  end,  and  then  blow  out  another  small  drop,  which  is  to  be 
deposited  on  the  central  disc ;  the  exact  amount  can  only  be  learnt  by 
practice.  Apply  the  cover-glass  carefully :  the  central  disc  should  be 
covered,  or  almost  covered,  by  the  fluid,  and  there  should  be  no  air- 
bubbles.  If  this  is  the  case,  or  if  the  fluid  runs  into  the  moat,  it  is  advis- 
able to  clean  the  slide  and  cover-glass,  and  take  a  fresh  drop. 

The  cover-glass  has  now  to  be  pressed  into  absolute  contact  with  the 
square  disc  which  supports  it,  so  as  to  spread  the  fluid  out  into  a  layer  just 
y1^  mm.  deep.  If  gentle  pressure  be  made,  say  with  a  needle,  on  the 
cover-glass  at  any  part  where  it  is  in  contact  with  the  glass  below  ;  a  series 
of  coloured  rings  will  be  seen  (Newton's  rings),  which  show  that  the  con- 
tact is  complete.  Pressure  should  be  made  in  this  way  at  the  four 


THE   ENUMERATION  OF  THE  LEUCOCYTES 


493 


corners  in  turn,  and  Newton's  rings  should  appear  and  persist  at  each.  As 
this  is  not  always  easily  accomplished  I  am  in  the  habit  of  clipping 
the  cover-glass  to  the  slide  by  means  of  four  pairs  of  Cornet's  forceps. 
Newton's  rings  are  formed  round  the  tip  of  each,  and  persist  as  long 
as  the  pressure  is  kept  up.  In  a  few  minutes  the  corpuscles  will  all  have 
settled  into  contact  with  the  disc,  and  the  exact  depth  of  the  cell  is  now 
immaterial,  so  that  the  forceps  may  be  removed. 

Proceed  to  count  the  leucocytes  in  the  following  way.  Focus  the  pre- 
paration under  the  £th  in.  lens,  using  a  narrow  diaphragm,  so  as  to  cut 
off  the  excess  of  light.  You  will  recognise  the  red  corpuscles,  which  will 
be  unstained  and  of  a  very  faint  yellow  colour,  and  the  leucocytes,  which 
are  now  coloured  violet.  If  you  have  the  centre  of  the  disc  in  the  field,  you 
will  see  that  it  is  traversed  by  fine  lines  crossing  each  other  at  right  angles, 
and  thus  marking  off  the  field  into  small  squares.  It  is  now  necessary  to 
arrange  the  length  of  the  tube  of  your  microscope  so  that  the  diameter  of 
the  whole  field  is  equal  to  that  of  eight  of  these  squares  (Fig.  222).  To  do 
this  it  is  usually  necessary  to  employ 
a  No.  2  eyepiece,  and  to  draw  out 
the  tube  of  the  microscope  a  little  ; 
but  the  conditions  are  readily  deter- 
mined by  experiment,  and,  when 
once  found,  should  be  noted  for 
future  use.  With  some  lenses  it  is 
not  possible  to  get  a  field  of  this 
In  this  case  you  will  probably 


' 


7 


size. 


FIG.  222.— THE  CEXTHAI.  Disc  OF  THE  COUMT- 
ING  CHAMBER  or  THOMA'S  H^MOCYTOKETER. 


be  able  to  get  one  equal  to  seven 
squares,  and  this  will  serve. 

Now  count  the  leucocytes  which  appear  on  any  field  of  the  microscope, 
and  note  down  their  number.  Move  the  slide  until  you  come  to  a  fresh 
field— and  it  is  here  that  the  mechanical  stage  is  such  an  advantage- 
and  count  these  also.  Proceed  in  this  way  until  you  have  counted  forty, 
or,  if  greater  accuracy  be  required,  eighty  fields,  and  add  up  the  total 
number  of  leucocytes  seen. 

The  calculation  is  now  very  simple.     If  you  have  counted  eighty  fi 
it  is  only  necessary  to  multiply  the  result  by  100,  or  if  forty  have  been 
counted,'  by  200,  to  obtain  the  numbers  per  cubic  millimetre.    The  figures 
thus  obtained  are  sufficiently  accurate  for  all  clinical  purposes.    In  mos 
cases  eighty  fields  should  be  counted  unless  the  first  forty  yield  figures  such 
that  the  diagnosis  is  fairly  certain,  i.e.  unless  you  can  say  definitely  that 
there  is  or  is  not  a  leucocytosis. 

In  health  a  count  made  with  the  microscope,  arranged  in  1 
should  show  an  average  of  about  one  leucocyte  per  field  (=  80  in  ft 
or  8000  per  cubic  millimetre).    An  average  of  two  per  field  indicate 
moderate  leucocytosis,  one  of  three  per  field  a  high  one. 

When  it  is  only  possible  to  obtain  seven  squares  in  the  diamet 


494  EXAMINATION  OF  THE   BLOOD 

the  field  it  is  necessary  to  count  104  fields  and  multiply  the  result  by  100, 
or  52  fields  and  multiply  by  200  to  get  the  number  per  cubic  millimetre. 

It  is  necessary  to  clean  the  haemocytometer  pipette  immediately  after 
use.  It  is  first  washed  out  once  or  twice  with  clean  water,  the  fluid 
being  sucked  up  in  the  ordinary  way,  and  expelled  by  being  blown  out  by 
means  of  an  india-rubber  ball,  such  as  is  attached  to  throat  sprays.  It 
is  then  washed  out  with  absolute  alcohol  or  rectified  spirit  in  the  same 
way,  and  then  with  ether,  and  after  this  has  been  expelled  by  the  india- 
rubber  puffer  a  stream  of  air  is  pumped  through  gently  until  the  interior 
of  the  whole  apparatus  is  quite  dry.  This  is  indicated  by  the  fact  that 
the  glass  ball  in  the  mixing  chamber  elicits  a  clear  ringing  sound  when  the 
pipette  is  shaken. 

In  health  the  leucocytes  range  between  four  and  ten  thousand  per 
cubic  millimetre,  or  may  even  rise  as  high  as  twelve  thousand  after  a 
meal.  The  presence  of  an  abnormally  high  number  is  termed  leucocytosis, 
and  this  occurs  in  a  large  number  of  conditions.  Thus  after  any  severe 
haemorrhage,  in  malignant  disease,  or  in  cachexia  of  any  kind,  there  is 
usually  a  moderate  leucocytosis,  and  the  numbers  may  rise  to  20,000  or 
even  higher.  There  is  frequently  a  rise  immediately  before  death  (agonal 
leucocytosis),  a  fact  which  has  occasionally  to  be  remembered  in  inter- 
preting the  result  of  a  blood-count  in  a  severe  illness. 

The  facts  mentioned  above  are  occasionally  of  value  in  diagnosis 
(thus  the  presence  of  a  marked  leucocytosis  in  a  patient  suffering  from 
a  tumour  is  some  evidence  of  its  malignancy),  but  the  greatest  value  of 
the  leucocyte  count  to  the  surgeon  arises  from  the  increased  counts 
present  in  infective  diseases,  especially  in  abscess  formation.  It  is  a 
general  rule  that  there  is  a  leucocytosis  in  most  infective  diseases,  the 
most  important  exceptions  being  tuberculosis,  typhoid  fever,  measles, 
and  malaria.  In  most  of  the  others  the  toxins  produced  by  the  infective 
agent  are  absorbed  into  the  blood  and  attract  the  leucocytes  (by  positive 
chemotaxis)  from  the  bone-marrow  in  increased  numbers ;  the  marrow 
is  also  stimulated,  and  the  cells  are  produced  in  excess.  The  conditions 
in  which  a  high  leucocytosis  occurs  are  therefore  (i)  a  great  production 
of  bacterial  toxins,  (2)  their  passage  into  the  blood.  To  these  we  must 
add  (3)  a  certain  degree  of  resistance  on  the  part  of  the  patient :  if  the 
intoxication  is  extremely  severe  or  the  patient's  resistance  low  the  leuco- 
cytes will  be  decreased  instead  of  being  raised  in  numbers.  This  pheno- 
menon is  rare,  and  it  is  usual  to  find  a  leucocytosis  even  in  severe 
infections ;  its  occasional  occurrence  hardly  detracts  from  the  value  of 
the  sign,  since  these  cases  are  commonly  diagnosed  without  difficulty, 
and  yield,  moreover,  the  other  blood-signs  of  an  acute  infection. 

The  practical  application  is  best  seen  in  the  diagnosis  of  the  presence 
or  absence  of  pus  in  acute  appendicitis  or  similar  inflammatory  condi- 
tions. Here  there  is  a  decided  rise  in  almost  every  case,  whatever  the 
exact  nature  of  the  pathological  conditions,  but  this  rise  is  usually 


THE  ENUMERATION  OF  THE  LEUCOCYTES  495 

moderate— not  exceeding  16,000  per  cubic  millimetre— if  no  pus  develops. 
But  if  the  organisms  are  sufficiently  powerful  to  lead  to  suppuration  the 
number  of  leucocytes  usually  rises  to  a  decidedly  higher  level,  and  figures 
of  20,000  to  30,000  are  commonly  met  with.  It  must,  however,  be  under- 
stood that  there  is  no  definite  figure  which  certainly  indicates  pus,  and 
the  true  test  as  to  the  nature  of  the  processes  which  are  taking  place  in 
the  affected  area  is  the  behaviour  of  the  leucocytes  from  day  to  day. 
With  a  rising  count  it  is  practically  certain  that  the  disease  is  progress- 
ing, and  when  the  count  begins  to  fall  it  may  be  regarded  as  a  strong 
indication  that  it  is  subsiding.  When  a  diagnosis  as  to  the  presence  or 
absence  of  pus  has  to  be  made  on  a  single  count  the  most  useful  rule  is 
to  regard  any  count  under  18,000  per  cubic  millimetre  as  indicating  the 
absence  of  suppuration;  whilst  numbers  above  this  increase  the  pro- 
bability of  there  being  pus  present  in  proportion  to  their  height,  and 
when  20,000  is  reached  the  disease  will,  with  very  few  exceptions,  turn 
out  to  be  suppurative. 

The  following  cautions  must  be  borne  in  mind  :  (i)  Many  other  con- 
ditions— pneumonia,  septicaemia,  etc.,  give  a  high  leucocytosis,  and  the 
test  loses  its  value  if  any  of  these  are  present  as  a  complication.  (2)  The 
leucocytosis  is  due  to  a  passage  of  the  toxins  into  the  tissues,  and  an 
abscess  that  is  draining  freely,  e.g.  into  the  bowel,  will  not  cause  much 
increase.  I  have  twice  seen  a  fall  in  the  number  of  leucocytes  consecu- 
tive to  a  rupture  of  an  appendicitic  abscess  into  the  intestine.  On  the 
other  hand,  in  cases  in  which  an  abscess  has  been  opened  and  the  fall  in 
the  leucocytes  which  indicates  the  free  escape  of  the  toxic  material  has 
occurred,  a  further  rise  indicates  either  the  formation  of  another  abscess 
or  the  obstruction  of  a  sinus  and  consequent  inefficient  drainage.  (3)  In 
old  thick-walled  abscesses  in  which  the  causative  bacteria  are  dead,  or 
at  least  latent,  there  is  no  leucocytosis  :  no  toxins  are  being  produced  to 
cause  it.  It  is  the  process  of  suppuration  and  not  the  presence  of  pus 
that  is  indicated  by  the  test.  Hence  (as  hinted  above)  a  fall  in  the 
number  of  leucocytes  does  not  necessarily  indicate  that  the  disease  is 
resolving  without  suppuration,  although  this  is  its  most  usual  significance. 
(4)  Tuberculous  abscesses  do  not  cause  leucocytosis  unless  a  secondary 
infection  with  pyogenic  bacteria  should  supervene.  (5)  Suppurative  in- 
flammation of  surfaces — such  as  that  of  the  bronchus,  intestine,  etc.,  are 
equivalent  to  abscesses  which  are  discharging  freely  and  cause  but 
moderate  leucocytosis. 

In  a  few  cases  of  acute  suppuration  where  there  is  a  large  surface 
involved  and  where  the  organism  is  extremely  virulent — e.g.  in  a  case  of 
general  peritonitis  occurring  in  the  course  of  a  severe  attack  of  puerperal 
fever — there  may  be  no  leucocytosis,  or  even  a  diminution  in  the  number 
of  leucocytes  (leucopenia).  This  is  of  extremely  ill  omen,  and  such 
patients  usually  die  very  quickly :  the  absence  of  leucocytosis  may  be 
taken  to  indicate  that  they  are  not  making  any  attempt  to  combat  the 


496  EXAMINATION  OF  THE  BLOOD 

infection.  Such  cases  are,  in  my  experience,  somewhat  rare,  and,  even 
in  very  severe  cases  of  peritonitis,  leucocytosis  is  the  rule.  When  they 
occur  the  diagnosis  (which  is  usually  obvious  to  the  clinician)  may  be 
made  from  the  differential  count  and  the  presence  of  a  well-marked 
iodine  reaction. 

Similarly,  a  leucopenia  may  arise  in  a  patient  suffering  from  severe 
exhaustion  and  malnutrition  even  when  the  infection  is  not  an  extremely 
severe  one.  Thus  when  perforation  occurs  in  typhoid  fever  there  is 
usually  a  well-marked  leucocytosis,  which  is  the  more  obvious  since  this 
disease  is  normally  associated  with  a  normal  number  of  leucocytes,  or 
with  a  leucopenia  :  in  most  cases  the  count  rises  to  15,000  within  half  an 
hour  or  so  after  the  perforation  occurs,  and  usually  rises  still  higher.  But 
when  perforation  takes  place  in  patients  who  have  been  greatly  reduced 
in  resisting  power  by  a  prolonged  attack  of  the  disease  this  rise  may  not 
take  place.  The  prognosis  is  then  unusually  bad. 

There  are  some  other  conditions  in  which  a  leucocyte  count  may 
be  of  value  to  the  surgeon. 

Malignant  tumours  are  usually  associated  with  a  moderate  leucocytosis 
— up  to  16,000  per  cubic  millimetre  or  possibly  a  little  higher,  whereas 
innocent  tumours  rarely  cause  any  alteration,  unless  they  are  inflamed  or 
sloughing.  This  may  be  of  occasional  value  in  diagnosis,  but  it  is  hardly 
necessary  to  point  out  that  it  affords  no  means  of  distinguishing  between 
a  malignant  tumour  and  an  inflammatory  mass.  The  leucocytosis  is, 
perhaps,  specially  constant  in  carcinoma  of  the  stomach,  whereas  in 
most  of  the  diseases  from  which  it  is  often  difficult  to  diagnose  it  the 
leucocytes  are  usually  reduced.  In  this  way  the  test  is  of  some  value, 
but  several  examinations  of  the  blood  should  be  made. 

In  glandular  enlargement,  in  which  the  diagnosis  lies  between  tubercle, 
Hodgkin's  disease,  and  lymphatic  leucocythaemia,  a  leucocyte  count  only 
affords  help  by  affording  a  means  whereby  the  last-named  condition 
may  be  diagnosed :  it  is  associated  with  a  large  increase  in  the  number 
of  leucocytes,  which  will  be  seen  to  be  mainly  lymphocytes  when  stained 
films  are  examined.  Tubercle  and  Hodgkin's  disease  are  indistinguish- 
able by  ordinary  examinations  of  the  blood.  A  few  differences  have 
been  described,  but  they  are  slight  and  far  from  constant,  and  in  either 
disease  the  blood  may  be  normal  for  long  periods. 


THE  DIFFERENTIAL  LEUCOCYTE  COUNT. 

The  differential  leucocyte  count  is  often  necessary  to  supplement  the 
information  obtained  by  the  count  obtained  in  the  method  described 
above.  The  most  convenient  method  is  to  spread  films  on  cover-glasses 
and  stain  them  by  Jenner's  method.  Square  cover-glasses  |th  in.  in 
diameter  are  best  to  use,  and  they  must  be  scrupulously  clean.  (Clean 


THE  DIFFERENTIAL  LEUCOCYTE  COUNT  497 

with  nitric  acid,  wash  in  water,  immerse  in  alcohol,  and  polish  with  a 
clean  handkerchief.)  To  prepare  the  films  prick  the  patient  as  before 
and,  holding  a  cover-glass  with  the  thumb  and  forefinger  of  your  right 
hand,  grasping  opposite  corners,  take  a  small  drop  of  blood— about  as 
big  as  the  head  of  a  large  pin— on  the  under  surface  of  the  glass.  Now 
take  another  cover-glass,  holding  adjacent  corners  between  the  thumb 
and  forefinger  of  your  left  hand,  and  place  this  glass  under  the  other, 
with  their  centres  coinciding,  and  let  the  upper  cover-glass  fall  into  the 
lower.  The  drop  of  blood  will  now  be  flattened  out  between  the  two 
glasses  and  should  just  fill  up  the  octagon  made  by  their  intersecting 
edges.  Then  take  hold  of  the  upper  cover-glass  again  and  slide  the  two 
apart.  You  should  now  have  two  good  films.  Allow  them  to  dry. 

To  stain  them  by  Jenner's  method  take  one  of  the  cover-glasses  in  a 
pair  of  Cornet's  forceps  (film  side  upward)  and  pour  on  a  few  drops  of 
the  stain,  which  may  be  bought  ready  prepared.  Allow  it  to  act  for 
three  or  four  minutes,  then  rinse  hi  distilled  or  clean  rain-water,  blot 
dry  between  two  pieces  of  blotting  paper,  dry  completely  over  a  flame, 
and  mount  in  balsam.  Examine  with  a  Jth  in.  or  TVth  in.  lens,  and 
make  a  count  of  400  leucocytes,  noting  down  each  sort  met  with,  and 
reduce  the  result  to  a  percentage. 

The  varieties  of  leucocytes  met  with  in  normal  blood  are : 
i.  The  lymphocytes.  These  have  circular  nuclei  with  a  variable  but 
usually  small  amount  of  protoplasm,  which  often  takes  the  blue  stain 
(by  Jenner's  method)  more  deeply  than  the  nucleus.  They  vary  in  size, 
some  being  about  as  large  as  the  red  corpuscles,  others  decidedly  larger. 
They  are  devoid  of  granules.  In  healthy  adults  they  usually  form  about 
25  per  cent,  of  the  total  leucocytes. 

2  Large  hyaline  or  large  mononuclear  cells  which  are  similar  to  the 
above,  but  larger,  and  have  indented  or  twisted  nuclei  and  protoplasm 
which  usually  stains  faintly.     They  form  about  1-4  per  cent,  of  the 
total  leucocytes,  and  may  be  counted  in  with  the  lymphocytes,  as  their 
variations  are  of  but  little  diagnostic  importance. 

3  Polynuclear  leucocytes,  which  have  twisted  (apparently  multiple) 
nuclei  and  fine  pink-staining  granules  hi  their  protoplasm.    The  latter 
may  not  be  seen  in  badly  stained  specimens,  but  the  characteristic  nuclei 
are  usually  sufficient  for  their  recognition.    They  form  about  60  to  75  per 
cent,  of  the  leucocytes,  and  are  the  cells  which  are  especially  increased 
in  inflammatory  conditions. 

4.  Eosinophiles,  which  have  also  twisted  (most  frequently  bilobed) 
nuclei  and  large  granules  which  stain  a  fine  pink  colour.    They  form 
about  1-4  per  cent  of  the  total  leucocytes,  and  are  usually  diminished 
in  severe  inflammatory  conditions,  the  diminution  being  roughly  pro- 
portional to  the  severity  of  the  inflammation  :  their  reappearance  in  the 
course  of  an  illness  of  this  nature  is  a  good  sign. 

5.  Mast  cells,  which  have  lobed  nuclei  and  blue-staining  granules. 


K  K 


498  EXAMINATION  OF  THE  BLOOD 

They  form  about  0^4  per  cent,  of  the  leucocytes,  and  are  decidedly  in- 
creased only  in  spleno-medullary  leucocythaemia. 

In  disease  we  may  meet  with  (6)  myelocytes,  which  are  of  variable 
size,  but  commonly  large,  and  have  single  circular  or  kidney-shaped 
nuclei  which  stain  faintly,  and  fine  pink-staining  granules  in  their  pro- 
toplasm Similar  cells,  but  with  large  granules,  are  called  (7)  Eosinophile 
myelocytes,  and  are  only  met  with  in  spleno-medullary  leucocythaemia. 

The  lymphocytes  are  greatly  increased  in  lymphatic  leucocythaemia, 
where  they  may  form  99  per  cent,  of  a  total  count  of  60,000-150,000 
leucocytes  per  cubic  millimeter  or  more.  They  are  increased  to  a  less 
extent,  and  often  only  relatively,  so  that  the  total  count  is  not  raised, 
in  a  variety  of  diseases,  the  most  important  of  which  are  pernicious 
anaemia,  tuberculosis  (when  not  complicated  by  suppurative  processes), 
typhoid  fever,  etc.  A  decrease  is  usually  only  apparent,  and  due  to 
an  increase  of  other  cells,  most  commonly  the  polynuclears. 

An  increase  of  the  polynuclears  is  the  most  characteristic  mark  of 
acute  inflammation,  occurring  especially  in  suppuration,  where  they 
form  85-95  per  cent,  of  the  whole.  This  is  of  great  importance  (i)  as 
confirmatory  of  the  results  obtained  by  the  estimation  of  the  number 
of  leucocytes  per  cubic  millimetre,  and  (2)  because  it  occurs  when  the 
leucocytosis  is  absent  from  any  cause,  e.g.  in  very  severe  septic 
processes. 

They  are  also  increased  in  other  conditions,  the  most  important  of 
which  are  spleno-medullary  leucocythaemia,  haemorrhage,  and  malignant 
disease. 

An  increase  of  eosinophiles  occurs  in  many  diseases,  the  most  important 
of  which  to  the  surgeon  are  those  dependent  on  animal  parasites,  e.g. 
trichinosis,  bilharzia  disease,  cysticercus  and  hydatid  disease.  Thus  in 
cases  in  which  the  diagnosis  lies  between  abscess  and  hydatids  of  the 
liver  an  eosinophilia,  even  though  slight,  points  to  the  latter  disease. 
There  is  also  a  large  increase  of  these  cells  in  spleno-medullary  leuco- 
cythaemia. 

The  following  special  cases  need  mention  : 

In  enlargement  of  the  spleen  a  blood  examination  may  be  necessary 
to  exclude  spleno-medullary  leucocythaemia,  which  is  characterised  by 
an  enormously  high  total  count  (averaging  some  400,000  per  cubic  milli- 
meter and  showing  the  presence  of  myelocytes,  eosinophile  myelocytes, 
and  large  mast  cells,  and  an  increased  number  of  polynuclears. 

In  enlargement  of  lymphatic  glands  the  examination  of  the  blood 
enables  lymphatic  leucocythaemia  to  be  diagnosed  or  excluded.  It  is 
characterised  by  a  large  increase  of  the  total  leucocytes  due  entirely  to 
an  increase  in  the  lymphocytes,  which  may  be  mostly  of  large  size.  In 
some  cases,  which  are  apparently  of  this  nature,  this  lymphocytosis  may 
occur  without  an  increase  in  the  total  number.  In  Hodgkin's  disease 
there  is  no  characteristic  change,  and  the  blood  may  be  normal  until  a 


THE  IODINE  REACTION  499 

cachectic  ansemia  supervenes.  In  tuberculosis  there  may  be  a  slight 
leucopema  with  a  relative  lymphocyte-sis,  but  this  is  rarely  sufficient  for 
a  diagnosis  :  in  a  small  proportion  of  cases  a  diagnosis  may  be  made 
from  the  opsonic  index. 


THE  IODINE  REACTION. 

The  study  of  the  iodine  reaction  or  glycogenic  degeneration  of  the 
leucocytes  is  simple,  and  often  leads  to  valuable  results.  Films  are  pre- 
pared as  before  and  mounted  (without  previous  fixation)  in 

Iodine i  part 

Iodide  of  potassium •,  partg 

Mucilage  of  gum  acacia IOO  parts. 

(This  solution  must  be  freshly  prepared.) 

They  are  allowed  to  stain  for  ten  minutes,  the  excess  of  the  fluid  blotted 
off,  and  they  are  examined  under  a  T^th.  in.  lens,  using  white  light. 
Normally  the  protoplasm  of  the  polynuclears  should  be  a  pale  yellow,  but 
in  acute  inflammatory  conditions,  more  especially  if  severe  enough  to  lead 
to  suppuration,  they  show  deep  mahogany  brown  granules  or  masses,  or 
may  stain  a  diffuse  brown  colour.  This  reaction  occurs  when  the  total 
count  is  not  raised.  It  may  be  present  in  other  conditions,  but  its  absence 
in  appendicitis  and  similar  diseases  is  strong  evidence  of  the  absence  of 
a  suppurative  lesion. 

THE  EXAMINATION  OF  THE  RED  CORPUSCLES  AND 
HEMOGLOBIN. 

The  enumeration  of  the  red  corpuscles  is  a  simple  but  somewhat 
tedious  proceeding,  and  is  rarely  of  much  value  to  the  surgeon.  The 
process  is  exactly  the  same  as  that  used  in  the  enumeration  of  the  leuco- 
cytes— in  fact,  it  is  now  customary  to  count  both  the  red  and  the  white 
corpuscles  in  the  same  specimen.  It  is  necessary  to  count  the  number 
of  red  corpuscles  which  lie  on  100  of  the  small  squares  into  which  the 
Thoma  counting-chamber  is  ruled.  This  may  be  done  by  counting  the 
squares  singly  and  noting  down  each  result,  or  by  counting  the  corpuscles 
which  lie  in  each  horizontal  '  bar '  of  twenty  squares.  It  will  then  be 
necessary  to  count  the  corpuscles  lying  on  five  such  bars.  The  calculation 
—presuming  that  the  blood  has  been  diluted  100  times — is  then  very 
simple :  the  total  number  in  100  squares,  multiplied  by  4000,  gives  the 
number  per  cubic  millimetre.  Thus,  if  650  corpuscles  were  found  in  the 
hundred  squares,  the  number  per  cubic  millimetre  would  be  650  X  4000 
=  2,600,000.  Greater  accuracy  will  be  obtained  by  preparing  a  second 
specimen  and  counting  another  100  squares  therein  :  the  two  results  are 
to  be  added  together  and  multiplied  by  2000. 

K  K   2 


500  EXAMINATION  OF  THE  BLOOD 

In  health  the  accepted  average  numbers  of  red  corpuscles  are,  for  the 
male,  5,000,000  per  cubic  millimetre,  and  for  the  female  4,500,000,  but 
these  numbers  are  not  infrequently  exceeded,  especially  in  dwellers  in  the 
country. 

The  chief  use  of  this  investigation  for  the  surgeon  is  that  it  provides 
some  measure  of  the  amount  of  blood  lost  in  a  haemorrhage,  and  enables 
its  regeneration  to  be  watched.  When  blood  is  lost  the  loss  involves 
corpuscles  and  plasma  in  equal  proportions,  and  an  examination  im- 
mediately afterwards  will  show  no  deviation  from  the  normal.  In  a  short 
time,  however,  fluid  will  be  absorbed  from  the  tissues,  so  that  the  volume 
of  the  blood  is  restored  to  its  former  amount,  and,  when  this  has  occurred, 
the  ratio  of  the  number  of  red  corpuscles  present  to  5,000,000  may  be 
taken  as  a  rough  guide  to  the  amount  of  blood  lost ;  thus,  in  the  example 
quoted,  where  the  number  per  cubic  millimetre  was  2,600,000,  very  nearly 
half  the  total  amount  must  have  escaped.  The  process  of  blood  re- 
generation almost  invariably  begins  by  a  rise  in  the  number  of  red  cor- 
puscles, which  occurs  earlier  and  proceeds  more  quickly  than  the  increase 
in  the  amount  of  haemoglobin ;  the  first  corpuscles,  which  are  manu- 
factured by  the  bone-marrow  in  response  to  the  unusual  demand,  being 
less  rich  in  pigment  than  they  should  be.  The  haemoglobin  is,  however, 
the  important  substance,  and  more  information  as  to  the  way  in  which 
the  regeneration  of  the  blood  is  proceeding  can  be  obtained  by  estimating 
the  amount  of  this  substance  than  by  counting  the  corpuscles. i 

The  most  useful  apparatus  for  measuring  the  amount  of  haemoglobin 
is  Haldane's  haemoglobinometer,  which  is  a  modification  of  that  of 
Gowers.  Its  use  involves  access  to  coal-gas  ;  and  as  this  is  not  always 
procurable  in  the  country,  it  is  advisable  to  procure  a  combination  instru- 
ment in  which  both  forms  are  available.  They  differ  only  in  the  standard 
which  is  employed  for  comparison.  In  Gowers's  instruments  this  consists 
of  a  tube  containing  a  jelly  tinged  with  carmine  to  a  tint  representing 
normal  healthy  blood  diluted  100  times.  In  Haldane's  the  standard 
(A)  is  a  solution  of  CO  haemoglobin  of  definite  strength  and  representing 
normal  blood  diluted  100  times,  and  saturated  with  CO  or  coal-gas.  To 
use  either  form,  place  a  little  water  in  the  diluting  tube  (B)  ;  prick  the 
patient  as  before ;  suck  blood  up  to  the  transverse  mark  on  the  special 
pipette  (D)  ;  place  the  tip  of  this  pipette  in  the  water  in  the  diluting 
tube  and  blow  out  the  blood,  washing  out  the  last  traces  by  sucking  up 
the  water  once  or  twice  and  expelling  it.  Shake  gently  so  as  to  mix 
the  blood  and  water  together. 

In  using  Gowers's  haemoglobinometer,  place  the  standard  in  a  good 
light  alongside  of  the  diluting  tube  :  the  solution  of  blood  in  this  should 
be  decidedly  darker  than  the  standard,  and,  if  this  is  not  the  case,  too 

1  Some  observers  estimate  the  specific  gravity  of  the  blood  instead  of  the  amount 
of  haemoglobin,  the  two  being  in  general  closely  related.  The  estimation  of  the 
specific  gravity  is,  however,  more  difficult,  and  is  rarely  required. 


EXAMINATION  OF  RED  CORPUSCLES  AND  H/EMOGLOBIN    501 

much  water  has  been  taken,  and  it  will  be  necessary  to  shake  it  all  out 
and  begin  again.  If  it  is  darker  than  the  standard  add  water  drop  by 
drop,  shaking  after  each  addition  until  the  two  just  match.  Now  read 
off  the  height  of  the  column  of  fluid  by  means  of  the  graduations  at  the 
side  of  the  tube  ;  these  indicate  the  amount  of  haemoglobin  expressed 
as  a  percentage  of  the  normal. 

In  Haldane's  form  the  blood  solution  has  to  be  saturated  with  coal- 
gas,  which  is  led  into  the  diluting  tube  by  means  of  the  apparatus  which 
is  sold  with  the  haemoglobinometer,  and  which  fits  over  an  ordinary  gas- 
jet  (G).  It  is  best  to  fill  the  tube 
with  gas,  and  quickly  cover  it  with 
the  finger  and  shake  for  a  few 
seconds.  Repeat  this  several 
times,  and  you  will  find  the  colour 
of  the  solution  changes  from 
crimson  to  pink,  the  tint  being 
exactly  like  that  in  the  compari- 
son tube.  Now  dilute  as  before 
until  the  two  are  an  exact  match. 
It  is  much  more  easy  to  deter- 
mine this  point  with  this  apparatus 
than  with  that  of  Gowers,  and  the 
results  are  more  accurate. 

The  amount  of  haemoglobin  is 
to  be  regarded  as  the  most  accu- 
rate criterion  of  the  degree  of 
anaemia  present.  Thus  it  occa- 
sionally happens  that  the  red 
corpuscles  are  present  in  normal 
numbers,  but  that  the  haemoglobin 
is  greatly  reduced,  and  in  such 
cases  the  patient  must  be  regarded 

as  being  anaemic  in  proportion  to  the  deficiency  in  haemoglobin,  in  spite 
of  the  normal  number  of  corpuscles. 

An  estimation  of  the  amount  of  haemoglobin  enables  the  surgeon  t. 
measure  roughly  the  amount  of  blood  lost,  and  where  the  haemoglobin 
falls  from  day  to  day— in  the  absence  of  other  causes  for  such  a  f; 
diagnosis  of  internal  haemorrhage  may  be  made  in  some  cases, 
have  been  laid  down  with  regard  to  the  suitability  of  patients  for  opei 
tion  in  presence  of  a  severe  anaemia,  but  these  can  be  of  li 
value      If  a  patient  is  decidedly  anaemic,  no  surgeon  would  cb 
operate  except  in  cases  of  necessity  ;   and  in  such  cases  he  wouL 
stay  his  hand  because  of  the  anaemia.     Still,  Mikulicz  s  rule  may  be 
quoted.     It  is  that  no  operation  should  be  done  on  patients  wit 
than  30  per  cent,  of  haemoglobin. 


FIG.  223. — HALDAXB'S  H^MOGLOBISOSIETE*. 

A,  Glass  tube  containing  blood  solution  of  standard 

tint. 

B,  Graduated  tube. 

C,  Rubber  stand  for  tubes  A  and  B. 

D,  Capillary  pipette  and  suction  tube ;  wire*  for 

cleaning  the  pipette  are  supplied. 

E,  Bottle  with  pipette  stopper. 

F,  Glass  tube  holding  six  lancets. 

G,  Tube  and    cap    for   fixing   over   ordinary    ga» 

burner. 


502  EXAMINATION  OF  THE  BLOOD 

The  examination  is  of  some  value  in  the  diagnosis  and  prognosis  of 
sepsis.  Localised  inflammatory  disorders  are  usually  accompanied  by  a 
moderate  degree  of  anaemia,  which  is  roughly  proportionate  to  the  extent 
and  severity  of  the  disease,  and  its  duration.  In  general  sepsis  this  is 
usually  much  more  marked,  and  the  haemoglobin  may  fall  to  a  very 
low  figure  in  a  few  days.  This  is  a  sign  of  very  bad  omen,  and  a  pro- 
gressive fall  in  the  haemoglobin  is  one  of  the  surest  indications  of  the  pro- 
gress of  the  disease.  On  the  other  hand,  a  cessation  of  the  fall,  or  a  rise, 
are  extremely  favourable  signs,  and  will  frequently  form  the  first  indi- 
cation of  a  turn  for  the  better.  This  is  especially  useful  in  puerperal  cases. 

Next  to  sepsis,  the  disease  in  which  anaemia  develops  most  rapidly 
is  malaria,  and  a  rapid  fall  of  the  haemoglobin  may  sometimes  permit  of 
a  diagnosis  between  this  disease  and  others  (such  as  pneumonia  or  typhoid 
fever)  in  which  the  anaemia  does  not  develop  so  quickly. 

The  term  '  colour  index '  is  used  to  denote  the  average  amount  of 
haemoglobin  contained  in  each  corpuscle,  the  normal  amount  being 
regarded  as  I.  To  obtain  it,  it  is  necessary  to  find  the  percentage  amount 
of  red  corpuscles  present,  5,000,000  being  regarded  as  normal ;  thus, 
2,000,000  red  corpuscles  per  cubic  millimetre  constitutes  40  per  cent,  of 
normal.  The  percentage  of  haemoglobin  present  is  then  divided  by 
the  figure  thus  obtained.  Thus,  if  in  the  example  just  quoted  there 
was  24  per  cent,  of  haemoglobin  in  the  blood  the  colour  index  would  be 
!£  =  o'6,  i.e.  each  corpuscle  would  contain  only  six-tenths  of  its  normal 
amount  of  haemoglobin. 

In  most  forms  of  anaemia  the  colour  index  is  slightly  below  unity : 
in  chlorosis  it  is  usually  very  low,  O'5  or  less  ;  and  in  pernicious  anaemia 
it  is  above  the  normal. 


THE  BACTERIOLOGICAL  EXAMINATION  OF  THE  BLOOD. 

This  is  a  matter  of  some  difficulty,  and  expert  help  should  be  called 
in  where  possible.  Cultures  are  necessary  in  almost  all  cases,  and  the 
blood  must  be  taken  direct  from  a  vein,  for  contaminations  are  almost 
certain  if  the  culture-material  is  taken  from  a  puncture  in  the  skin,  no 
matter  how  carefully  this  may  have  been  sterilised.  I  prefer  a  special 
pipette  made  like  a  hypodermic  syringe,  but  longer,  and  devoid  of  a 
piston  ;  but  in  the  absence  of  this,  an  all-glass  5  c.c.  or  10  c.c.  exploring 
syringe  will  answer  very  well.  Cultures  should  be  made  in  broth  and  on 
the  surface  of  a  solid  medium,  such  as  agar  or  blood  serum,  and  these 
materials  must  be  at  hand  at  the  time  of  the  operation. 

Proceed  as  follows  :  Put  the  syringe  in  a  steriliser  to  boil ;  it  should 
be  kept  at  the  boiling  point  for  at  least  ten  minutes,  and  should  be  allowed 
to  cool  spontaneously  before  being  removed  from  the  water.  Prepare 
the  skin  over  the  antecubital  fossa  as  though  for  an  operation,  washing  off 
the  antiseptic  used  by  means  of  a  stream  of  methylated  spirit  immediately 

t   ~Jj   3  f j  3  J  . 


THE  OPSONIC  INDEX  503 

before  the  puncture  is  made.  Place  a  narrow  ligature  round  the  upper 
arm  and  tie  it  fairly  tightly,  so  as  to  obstruct  the  veins.  Select  a  large  and 
prominent  vein,  and  (having  fitted  the  syringe  together)  puncture  it  by 
passing  the  hypodermic  needle  obliquely  through  a  fair  thickness  of 
skin  ;  by  doing  so  you  will  lessen  the  chance  of  skin  contamination  and 
of  leakage  of  blood  after  the  operation.  Direct  the  point  of  the  needle 
away  from  the  body,  so  as  to  face  the  current  of  blood,  and  as  soon  as  the 
vein  is  entered  the  blood  will  commence  to  rise  in  the  syringe,  pushing 
the  piston  before  it ;  it  is  unnecessary,  and  indeed  useless,  to  apply  suction. 
When  the  requisite  amount  has  been  taken,  withdraw  the  needle  and  get 
an  assistant  to  remove  the  ligature  ;  if  this  is  not  done  there  may  be 
leakage  into  the  tissues.  A  pad  of  cotton-wool  applied  with  collodion  will 
usually  be  sufficient  dressing  for  the  puncture. 

The  cultures  must  be  made  at  once,  or  the  blood  will  coagulate.  In 
most  cases  the  best  way  to  proceed  is  to  squirt  a  few  drops  on  to  the  sur- 
face of  an  agar  tube,  to  put  about  I  c.c.  into  an  ordinary  broth  tube,  and 
the  rest  into  a  small  flask  holding  some  100  c.c.  of  broth.  These  are  to  be 
incubated  at  the  body  temperature,  and  will  (in  positive  cases)  usually 
show  signs  of  growth  in  24-36  hours,  though  sometimes  there  may  be  no 
appearance  of  bacteria  before  the  end  of  the  third  day.  For  the  methods 
of  examining  these  cultures  and  the  identification  of  the  various  organisms 
which  may  be  present  a  work  on  bacteriology  must  be  consulted. 

THE  OPSONIC  INDEX. 

The  method  by  which  the  opsonic  index  is  estimated  is  fully  described 
by  Dr.  Whitfield  (see  Vol.  II.),  and  its  application  to  diagnosis  is  all  that 
need  be  discussed  here.     It  is  rarely  required  except  in  the  diagnosis 
of  tuberculous  infections,  and  it  is  in  these  that  it  has  been  most  carefully 
studied.     Unfortunately  it  is  only  in  a  comparatively  small  minority  of 
cases  that  it  is  of  value,  since  it  is  found  that  a  patient  suffering  from 
tuberculosis  may  have  a  perfectly  normal  index  as  compared  with  a 
healthy  person.     This,  however,  is  not  always  the  case,  and  it  is  common 
to  find  tuberculous  patients  having  indices  decidedly  higher  or  lower  than 
any  met  with  in  healthy  persons  ;  thus  it  may  fall  to  03  or  rise  as  high 
as  2.     In  health  the  extreme  limits  may  be  regarded  as  0'8  and  i'2,  2 
the  figures  below  or  above  these  may  be  looked  upon  with  suspici 
proportional  to  their  remoteness  from  these  limits  ;  thus,  0'5  or  1-5  almos 
certainly  indicate  tuberculosis. 

Another  method  which  may  be  of  value,  where  the  simple  deten 
ation  of  the  opsonic  index  yields  inconclusive  results,  is  to  follow  r 
injection  of  tuberculin  such  as  is  now  used  therapeutically— say  ^  o 
milligram  of  new  tuberculin.     This  is  apparently  quite  harmless 
cases,  and  is  usually  not  followed  by  any  febrile  reaction.     In  h 
does  not  usually  cause  any  fall  of  the  opsonic  index,  whereas  when 


504  EXAMINATION  OF  THE  BLOOD 

is  a  tuberculous  lesion  present  there  is  a  marked  fall  of  the  index  (negative 
phase)  followed  by  a  rise,  in  most  cases  to  a  higher  level  than  the  original 
one.  When  this  examination  is  made  the  determination  must  be  per- 
formed with  great  accuracy  and  repeated  in  twenty-four  hours,  and  again 
in  a  day  or  two,  since  the  negative  phase  may  be  very  short  or  may  be 
delayed.  The  results  are  more  certain  if  a  larger  dose  of  tuberculin  is 
given,  but  this  is  not  always  desirable. 

The  following  cautions  should  be  noted.  The  determination  of  the 
opsonic  index  is  by  no  means  an  easy  process,  and  even  in  skilled  hands 
there  is  necessarily  a  certain  amount  of  error.  As  ordinarily  performed 
this  may  amount  to  10  per  cent,  or  so,  though  with  great  pains  it  may  be 
reduced  somewhat :  hence  no  importance  should  be  attached  to  small 
differences.  Secondly,  the  opsonic  index  affords  no  clue  to  the  locality 
or  the  size  of  a  tuberculous  lesion.  In  the  third  place,  the  opsonic 
index  does  not,  at  present,  afford  any  indication  as  to  prognosis. 

THE  FREEZING  POINT  OF  THE  BLOOD  OR  SERUM. 

The  freezing  point  of  the  blood  or  serum  is  sometimes  estimated,  the 
results  obtained  being  thought  to  indicate  the  functional  activity  or  the 
reverse  of  the  kidneys,  and  to  allow  an  estimate  of  the  danger  of  an  opera- 
tion to  be  formed  when  these  organs  are  affected.  The  freezing  point  of 
any  watery  solution  is  an  index  of  its  molecular  concentration  :  the  greater 
the  number  of  molecules  it  contains  the  lower  the  freezing  point.  In  health 
the  kidneys  excrete  the  salts  which  occur  in  the  blood,  passing  them  into 
the  urine,  so  that  the  freezing  point  of  the  blood  should  remain  constant 
and  at  a  higher  level  than  that  of  the  urine.  In  disease  this  may  not 
occur,  and  one  of  the  most  constant  signs  of  functional  imperfection 
of  the  kidney  is  a  lowering  of  the  freezing  point  of  the  blood  due  to  a 
retention  of  salts,  etc.,  which  should  be  eliminated  by  the  kidneys.  In 
health  the  blood  usually  freezes  at  —  0'56°  C.,  and  when  this  is  the  case  we 
may,  as  a  general  rule,  deduce  that  the  function  of  elimination  is  being 
performed  efficiently.  Thus,  when  one  kidney  is  known  to  be  diseased, 
and  the  blood  freezes  at  this  point,  it  is  highly  probable  that  the  remaining 
kidney  is  sound,  and  capable  of  acting  as  an  eliminator  for  the  whole  of 
the  body.  On  the  other  hand,  a  decided  fall  in  the  freezing  point  (to  —  o  '6° 
or  lower)  is  more  likely  to  indicate  a  lesion  of  both  kidneys,  and  a  danger 
of  uremia  after  nephrectomy,  or  the  performance  of  any  severe  surgical 
operation.  Unfortunately,  however,  these  results,  though  generally 
true,  are  subject  to  numerous  exceptions  ;  thus  the  freezing  point  of  the 
blood  may  be  lowered  in  any  condition  leading  to  cyanosis,  in  severe 
anaemia,  diabetes,  etc.  Further,  if  the  blood  is  hydraemic  to  begin  with, 
renal  disease  may  lower  the  freezing  point  until  it  reaches  the  normal, 
and  the  examination  of  the  blood  will  show  no  deviation  from  the  healthy 
condition. 


THE  FREEZING  POINT  OF  THE  BLOOD  OR  SERUM   505 

A  great  objection  to  the  use  of  this  method  is  that  large  amounts  of 
blood — 10  c.c.  or  more — are  necessary.  This,  together  with  the  uncertain 
interpretation  to  be  placed  upon  the  results  which  it  yields,  prevents  it 
from  being  used  much,  in  this  country  at  least.  The  process  for  the 
determination  of  the  freezing  point  is  not  difficult,  and  the  results  obtained 
are  very  accurate.  It  is  fully  described  in  Ewing's  '  Clinical  Pathology  of 
the  Blood.' 

The  examination  of  the  molecular  concentration  of  the  blood  (or 
serum)  and  of  the  urine  which  is  being  secreted  at  the  time  the  blood  is 
taken  is  of  greater  promise.  It  may  be  carried  out  by  the  determination 
of  the  freezing  points  of  the  two  substances,  or  by  a  method  due  to  Wright 
(Lancet,  April  2,  1904,  and  October  21,  1905)  which  has  the  great  advan- 
tage that  only  a  very  small  amount  of  serum  is  necessary.  It  depends 
upon  the  fact  that  red  blood  corpuscles  are  hsemolysed  in  distilled  water  or 
in  solutions  of  salts  below  a  certain  molecular  concentration  about  equal  to 
that  of  o  '42  per  cent.  NaCl.  The  patient  is  made  to  empty  his  bladder  and 
a  sample  of  blood  is  collected.  As  soon  as  possible  after  this  he  is  again 
made  to  empty  his  bladder,  and  a  sample  of  urine  thus  obtained.  Various 
dilutions  of  the  serum  and  of  the  urine  are  now  made  with  distilled  water, 
and  to  each  a  definite  volume  of  blood  (or  an  emulsion  of  blood  corpuscles) 
is  added.  This  is  done  by  means  of  a  capillary  pipette,  with  a  very  fine 
point  at  one  end  and  an  india-rubber  nipple  at  the  other,  and  similar  to 
those  used  for  the  determination  of  the  opsonic  index.  A  unit  mark  is 
made  at  about  one  inch  from  the  tip,  and  two  volumes  of  the  dilution  of 
the  serum  or  urine  are  taken  and  one  of  the  blood  or  emulsion  or  red  cor- 
puscles. These  are  mixed  together  and  sucked  up  into  the  pipette.  This 
is  examined  by  reflected  light  to  determine  whether  the  corpuscles  are 
completely  hsemolysed  :  if  this  is  the  case  the  fluid  will  be  translucent  and 
appear  dark  by  reflected  light,  whereas  if  the  corpuscles  are  intact  it  will 
be  opaque  and  appear  much  lighter  by  reflected  light.  When  a  series  of 
these  dilutions  is  made  and  sucked  into  one  pipette  (each  separated  by  a 
small  column  of  air),  the  point  at  which  complete  haemolysis  occurs  is 
readily  seen. 

In  health,  or  in  the  absence  of  renal  disease,  the  urine  should  contain 
a  greater  amount  of  salts,  etc.,  than  the  serum,  and  thus  should  require 
greater  dilution  in  order  to  bring  about  complete  haemolysis.  Thus  if 
the  urine  just  haemolyses  when  diluted  16  times  with  distilled  water,  the 
serum  ought  to  do  so  when  diluted  about  8  times  :  the  excretory  coefficient 
is  then  *£.  =  2.  This  coefficient  is  usually  atxnit  2*2  when  the  kidneys 
are  healthy  :  when  they  are  diseased  it  may  fall  to  i  or  lower.  In  order 
to  get  reliable  information  the  patient  should  not  have  drunk  copiously 
immediately  before  the  samples  are  taken,  and  his  food  for  some  time  pre- 
viously should  contain  a  fair  amount  of  salts,  otherwise  the  kidneys  may 
not  be  called  upon  to  perform  as  much  work  as  they  are  capable  of  doing. 
When  performed  in  this  way  the  test  appears,  as  far  as  our  experience  has 


506  EXAMINATION   OF  THE  BLOOD 

gone  at  present,  to  be  a  reliable  one,  although  a  large  amount  of  informa- 
tion is  still  necessary  before  the  information  which  it  yields  can  be  regarded 
as  conclusive. 

SUMMARY. 

The  following  is  a  brief  resume  of  the  condition  of  the  blood  in  some 
of  the  diseases,  in  which  it  may  afford  some  assistance  in  diagnosis. 

Suppuration. — There  is  a  marked  leucocytosis,  the  numbers  rising  to 
about  18,000,  or  usually  higher.  The  increase  is  due  mainly  to  an  in- 
creased influx  of  polynuclear  cells,  which  may  form  95  per  cent,  of  the  total 
leucocytes  :  the  lymphocytes  and  eosinophile  cells  are  reduced,  especially 
the  latter.  The  glycogenic  degeneration  of  the  leucocytes  is  well 
marked. 

The  red  corpuscles  show  no  change,  or,  in  severe  cases,  there  may 
be  a  slight  anaemia. 

Sepiiccemia. — The  changes  in  the  leucocytes  are,  in  general,  similar  to 
those  of  the  localised  suppuration,  but  in  very  severe  cases  there  may  be 
leucopenia  instead  of  leucocytosis :  the  relative  increase  of  the  poly- 
nuclears  and  diminution  of  the  lymphocytes  and  eosinophiles  will  occur, 
and  the  glycogenic  degeneration  is  usually  very  obvious. 

A  progressive  anaemia  is  the  rule,  and  the  amount  of  haemoglobin  lost 
from  day  to  day  may  be  taken  as  a  rough  guide  as  to  the  severity  of  the 
infection. 

A  bacteriological  examination  of  the  blood  will  probably  show  the 
presence  of  pathogenic  bacteria,  but  this  is  not  always  the  case  unless 
repeated  examinations  are  made. 

Tuberculosis. — In  uncomplicated  tubercle  there  is  usually  no  change 
other  than  a  slight  leucopenia  with  a  relative  increase  of  the  lymphocytes. 
These  alterations  are,  as  a  rule,  insufficient  to  justify  a  diagnosis.  The 
red  corpuscles  are  unchanged,  except  in  the  later  stages,  in  which  the 
patient  becomes  cachectic. 

A  diagnosis  may  be  made  in  a  certain  proportion  of  cases  by  means 
of  the  opsonic  index. 

In  tuberculous  meningitis  there  is  a  decided  leucocytosis,  which  may 
reach  25,000.  Tuberculous  pleurisy  is,  as  a  rule,  unaccompanied  by 
leucocytosis,  but  there  may  be  a  slight  rise. 

The  occurrence  of  a  secondary  infection,  e.g.  in  a  tuberculous  abscess 
or  sinus,  causes  the  appearance  of  the  blood  changes  described  under  the 
heading  of  suppuration. 

Syphilis. — In  the  earlier  stages  the  blood  is  usually  normal ;  if  the 
cases  is  severe,  there  may  be  slight  anaemia. 

In  the  secondary  stage  there  is  marked  anaemia,  in  which  the  haemo- 
globin may  fall  to  40  per  cent/or  lower,  and  a  moderate  leucocytosis  (not 
often  exceeding  15,000)  due  mainly  to  an  increase  of  lymphocytes. 

In  the  tertiary  stage  there  is  nothing  characteristic,  though  in  cachectic 


SUMMARY  507 

cases  there  may,  of  course,  be  a  slight  anaemia  with  or  without  moderate 
leucocytosis. 

Malignant  Disease.— In  the  early  stages  there  may  be  nothing  abnor- 
mal, or  there  may  be  a  slight  polynuclear  leucocytosis  ;  it  is  rarely  sufficient 
to  help  much  in  the  diagnosis.  In  later  stages  there  is  usually  a  marked 
polynuclear  leucocytosis,  more  marked  in  the  sarcomata  than  in  the 
carcinomata,  and  in  ulcerated  than  in  non-ulcerated  tumours.  Anaemia 
frequently  occurs  (but  not  always,  the  blood  sometimes  appearing  to 
diminish  in  total  volume  rather  than  to  become  impoverished),  and 
nucleated  red  corpuscles  (normoblasts)  may  be  present  in  considerable 
numbers. 

In  carcinoma  of  the  oesophagus  there  may  be  a  leucopenia. 

In  cancer  of  the  stomach  the  leucocytosis,  anaemia,  and  presence  of 
nucleated  red  corpuscles  is  usually  well  marked.  In  most  cases  the 
anaemia  is  of  the  ordinary  secondary  variety,  with  a  low  colour-index ; 
whilst  in  others  the  colour-index  is  high,  and  the  blood-count  closely 
resembles  that  of  pernicious  anaemia,  from  which  it  may  be  distinguished 
by  the  presence  of  polynuclear  leucocytosis  in  place  of  the  leucopenia 
and  lymphocytosis  met  with  in  the  other  condition. 

Lymphadenoma. — In  the  early  stages  the  blood  is  unaltered  in  any 
way.  In  the  later  there  is  the  ordinary  secondary  anaemia,  and  frequently 
moderate  leucocytosis.  It  is  worth  while  to  emphasise  the  fact  that  the 
disease  cannot  be  diagnosed  by  a  blood  examination. 

LeucocythcBtnia. — In  the  spleno-medullary  form  there  is  a  vast  excess 
of  leucocytes  (250,000  or  more),  which  are  seen  to  consist  in  large  measure 
of  myelocytes.  There  is  an  excess  of  mast  cells,  often  of  large  size,  of 
eosinophile  cells,  and  of  polynuclear  cells,  and  eosinophile  myelocytes  are 
present.  There  is  anaemia,  of  the  secondary  type,  and  nucleated  red  cor- 
puscles are  usually  present.  The  disease  may  be  diagnosed  in  most  cases 
by  a  single  glance  at  a  stained  film. 

Lymphatic  Leucocythamia. — This  is  associated  with  a  great  increase  of 
the  leucocytes,  usually  to  100,000  or  more,  but  spmetimes  to  a  much 
lower  figure ;  and  occasionally  in  diseases  apparently  of  this  type  the 
total  numbers  are  normal.  In  all  cases,  however,  the  relative  number 
of  the  lymphocytes  is  greatly  raised,  sometimes  to  99  per  cent.  There 
is  also  secondary  anaemia. 

Pernicious  Anemia.— This  is  associated  by  a  raised  colour  index, 
which  may  be  as  high  as  i'8,  or  even  more ;  the  red  corpuscles  are 
reduced  out  of  proportion  to  the  haemoglobin.  Thus  it  is  common  to 
find  about  1,000,000  red  corpuscles,  and  when  this  is  the  case  the 
haemoglobin  may  be  25-30  per  cent.,  instead  of  the  normal  20  per 
cent.  The  red  corpuscles  are  abnormal,  being  larger  than  normal 
(macrocytes),  small  (microcytes) ,  or  distorted  (poikilocytes).  Nucleated 
corpuscles  occur,  especially  the  large  forms  (megaloblasts),  which  are 
almost  characteristic  of  this  disease. 


508  EXAMINATION  OF  THE  BLOOD 

The  leucocytes  are  diminished  in  numbers,  and  there  is  a  relative 
excess  of  lymphocytes  (40  per  cent,  or  more). 

Chlorosis  is  indicated  by  a  low  colour  index  (0*5  or  often  less),  the 
leucocytes  remaining  normal. 

Secondary  ancemia  (i.e.  that  due  to  a  definite  recognisable  cause)  is 
indicated  by  a  moderately  reduced  colour  index  (o-8  or  0^9,  sometimes 
lower),  with  a  leucocytosis,  slight  or  marked,  according  to  the  disease 
producing  it,  and  caused  mainly  by  an  increase  of  the  polynuclears. 

Typhoid  Fever. — In  the  earlier  stages  there  is  usually  no  anaemia,  and 
there  may  even  be  an  increase,  due  to  a  concentration  of  the  blood. 
There  is  no  leucocytosis,  the  numbers  being  often  below  normal,  and 
there  is  a  relative  excess  of  lymphocytes.  In  the  later  stages  there  may 
be  a  moderate  amount  of  anaemia. 

Perforation  of  a  Viscus. — Here  there  is  a  sudden  and  rapid  increase  in 
the  number  of  leucocytes,  the  figures  reached  being  dependent  on  the 
amount  of  fluid  which  escapes,  its  nature,  and  the  resisting  powers  of 
the  patient.  The  increase  is  mainly  due  to  the  polynuclear  cells. 

In  the  case  of  a  perforated  typhoid  ulcer  the  rise  is  usually  well 
marked,  since  it  contrasts  with  the  low  counts  previously  met  with.  A 
severe  haemorrhage  may  give  a  similar  rise,  and  must  be  excluded. 

Trichinosis,  Bilharzia  Disease,  Hydatids,  etc. — The  characteristic  feature 
of  these  diseases  is  an  increase  in  the  eosinophiles.  This  is  most  marked  in 
trichinosis,  where  it  may  reach  80  per  cent..  It  is  least  marked  in  hydatid 
disease,  and  may,  indeed,  be  absent.  In  swellings  of  the  liver  in  which 
hydatid  is  suspected  a  considerable  amount  of  weight  attaches  to  even  a 
slight  increase,  since  the  most  important  diseases  with  which  it  may  be 
confounded  are  usually  associated  with  diminished  eosinophiles.  In  this 
connection  anything  over  4  per  cent,  may  be  looked  upon  with  suspicion. 

Malaria. — The  diagnostic  feature  is,  of  course,  the  discovery  of  the 
specific  parasite.  This  is  not  always  possible,  and,  when  it  cannot  be 
done,  some  help  may  be  obtained  from  the  fact  that  there  is  no  leuco- 
cytosis, but  a  relative  lymphocytosis,  large  lymphocytes  being  specially 
numerous.  The  anaemia  is  usually  of  very  rapid  onset,  a  marked  re- 
duction occurring  in  a  few  days. 


THE  WASSERMANN  REACTION. 

One  of  the  most  important  services  that  pathology  has  been  able  to 
render  to  clinical  surgery  for  some  years  is  the  elaboration  of  a  method 
for  the  diagnosis  of  syphilis  by  means  of  a  blood-test,  the  great  advantage 
of  which  is  that  it  can  always  be  carried  out  in  cases  in  which  there  is  no 
available  material  in  which  the  specific  spirochaete  can  be  sought.  It  is 
somewhat  difficult  to  perform,  and  hence  is  not  available  as  a  consulting- 
room  test,  but  the  collection  of  the  necessary  sample  of  blood  is  easy 


THE  WASSERMANN  REACTION  509 

(sufficient  being  obtained  from  an  ordinary  puncture  of  the  finger  or 
ear-lobe)  and  in  skilled  hands  it  yields  trustworthy  results. 

It  is  based  on  the  phenomenon  known  as  the  '  absorption  of  com- 
plement '  and  discovered  by  Bordet  and  Gengou.  To  understand  this 
it  is  necessary  to  be  familiar  with  the  terms  '  antigen '  and  antibody.' 
An  antigen  is  a  substance  (apparently  invariably  of  proteid  nature)  which, 
when  injected  into  an  animal  in  which  it  does  not  occur  naturally,  gives 
rise  to  the  production  of  a  second  substance,  its  antibody.  Thus  diph- 
theria toxin  is  an  antigen,  its  antibody  being  diphtheria  antitoxin. 
Solutions  of  coagulable  proteids  (blood-serum,  etc.)  act  as  antigens, 
giving  rise  to  precipitins :  bacteria,  red-blood  corpuscles  and  other 
cells  are  antigens  which  give  rise  to  a  series  of  antibodies,  amongst  which 
are  agglutinins  and  cytolysins.  These  latter  are  substances  of  much 
importance  in  regard  to  the  Wassermann  reaction.  They  are  antibodies 
which  have  the  power  of  dissolving  their  antigens  (or  rather  the  cells 
containing  them)  on  condition  that  a  third  substance  is  present  and  that 
the  three  bodies  are  kept  at,  or  near,  the  temperature  of  the  body.  This 
third  substance  is  called  complement  or  alexin,  and  it  is  not  an  antibody ; 
it  occurs  in  normal  blood-serum  and  is  supposed  to  play  a  part  of  great 
importance  in  preserving  the  body  against  infections.  It  differs  from 
the  antibodies  in  being  thermolabile,  i.e.  it  is  destroyed  at  a  temperature 
°f  55°  C.  in  half  an  hour  or  at  60°  C.  in  ten  minutes. 

Let  us  take  an  example  of  the  action  of  these  substances.  If  normal 
rabbit's  serum  be  mixed  with  sheep's  corpuscles  (thoroughly  washed  in 
normal  saline  solution  by  repeated  centrifugalisations)  and  incubated, 
no  action  takes  place.  If,  however,  the  rabbit  be  injected  once  or  twice 
at  intervals  of  a  few  days  with  these  washed  corpuscles,  it  acquires  fresh 
properties ;  and  if  the  experiment  be  repeated,  using  the  serum  of  this 
'  immunised  '  rabbit,  it  will  be  seen  that  this  has  a  solvent  action  on  the 
sheep's  corpuscles  ;  in  the  former  case  the  latter  will  settle  to  the  bottom 
of  the  tube,  leaving  a  colourless  supernatant  layer  of  normal  saline  solu- 
tion, whilst  in  the  latter  they  will  be  dissolved  and  yield  a  crimson 
solution,  in  which  practically  no  deposition  of  undissolved  material  takes 

place. 

That  this  new  solvent  property  depends  upon  the  action  c 
substances,  an  antibody  formed  as  the  result  of  the  injection,  and  com- 
plement occurring  in  normal  serum,  is  provable  thus  :   the  serum  from 
the  immunised  animal  is  heated  to  55°  C.  for  half  an  hour,  so  as  to  destroy 
the  complement,  and  then  incubated  with  the  washed  corpuscles;  no 
solution  takes  place.     A  little  fresh  serum  from  a  normal  (unimmunis 
rabbit  is  then  added,  and  the  mixture  re-incubated,  when  solution  oca 
This  shows  that  the  heated  serum  of  an  immunised  animal  i 
powerless  to  effect  solution ;  we  have  seen  previously  that  fresh  normal 
serum  is  equally  unable,  but  the  two  together  can  do  so.     Further  expei 
ments  show  that  the  antibody  (which  is  also  known  as  amboceptor,  immur 


510  EXAMINATION  OF  THE  BLOOD 

body,  etc.)  can  enter  into  combination  with  the  corpuscles  at  a  low 
temperature,  and  corpuscles  thus  treated  are  spoken  of  as  '  sensitised. ' 
In  appearance  they  are  unaltered,  and  when  fresh  normal  serum  is  added 
nothing  happens  until  the  mixture  is  raised  to  a  point  near  the  temperature 
of  the  body,  when  solution  occurs.  Thus  we  picture  the  process  of 
haemolysis  thus  :  the  antibody  unites  to  the  corpuscles,  but  without 
injuring  them.  If  now  complement  be  added  it  can  unite  either  with 
the  antibody  or  with  the  sensitised  corpuscle  (for  this  point  is  not  yet 
settled),  yet  still  without  the  occurrence  of  solution  unless  the  mixture 
be  near  the  body-temperature,  when  the  complement  exerts  its  enzyme- 
like  action  and  solution  occurs. 

All  cells  (with  perhaps  a  few  exceptions)  appear  able  to  give  rise  to 
similar  antibodies,  amongst  others,  the  bacteria.  Thus,  the  experiments 
described  above  could  be  carried  out  equally  well,  using  cholera  vibrios 
instead  of  sheep's  corpuscles.  The  serum  of  an  animal  which  has  been 
immunised  to  this  organism,  contains  an  antibody  which  will  sensitise  it 
to  the  action  of  the  complement  contained  in  the  normal  serum.  These 
antibodies  are  more  or  less  specific,  i.e.  that  for  sheep's  corpuscles  will 
have  no  action  on  cholera  vibrios  and  vice  versa. 

The  discovery  made  by  Bordet  and  Gengou,  and  since  shown  to  be 
of  universal  validity,  was  that  when  an  antibody  and  its  antigen  unite 
all  the  complement  is  removed  from  the  serum.  For  example,  if  we 
mix  together  cholera  vibrios  (antigen),  heated  serum  from  a  rabbit  which 
has  been  immunised  to  cholera  (antibody),  and  fresh  rabbit  or  guinea-pig 
serum  (complement)  and  incubate  them,  all  the  complement  will  be 
removed,  and  this  is  proved  by  adding  sheep's  corpuscles  sensitised  by 
heated  serum  from  an  immunised  rabbit.  No  solution  occurs,  showing 
that  the  fluid  contains  no  complement.  This  gives  us  a  most  delicate 
and  sensitive  test  for  the  presence  of  an  antigen  or  of  an  antibody. 

It  was  applied  by  Wassermann  to  the  diagnosis  of  syphilis.  The 
first  difficulty  was  to  obtain  the  antigen,  pure  cultures  of  the  spirochaete, 
being,  of  course,  unobtainable.  To  overcome  this,  he  made  use  of  an 
extract  (in  normal  saline  solution)  of  the  liver  of  a  still-born  syphilitic 
foetus  found  to  be  rich  hi  spirochaetes.  This  we  shall  call  the  '  extract ' 
or  '  antigen.'  The  patient's  blood  is  now  to  be  tested  for  an  antibody 
to  the  spirochaete,  and  as  a  preliminary,  it  is  heated  to  55°  C.  to  destroy 
its  complement  (this  step  is  not  absolutely  necessary).  A  mixture 
is  now  prepared  of  (i)  extract  or  antigen,  (2)  the  heated  serum 
to  be  tested,  and  (3)  guinea-pig's  serum,  quite  fresh  and  rich  in  comple- 
ment. The  three  are  heated  together  for  an  hour  hi  the  incubator,  so 
as  to  allow  the  union  of  the  three  substances  to  take  place,  supposing,  of 
course,  that  the  syphilitic  antibody  is  present.  Then  a  mixture  of  (4) 
sheep's  corpuscles  and  (5)  heated  serum  from  a  rabbit  immunised  to 
sheep's  corpuscles  is  added,  and  the  mixture  again  incubated  for  two 
hours  and  allowed  to  stand  in  the  cold  for  twelve  hours.  A  positive 


THE  WASSERMANN  REACTION  5II 

reaction  is  indicated  by  the  fact  that  the  corpuscles  remain  undissolved  and 
form  a  compact  layer  at  the  bottom  of  colourless  fluid,  whereas  when 
the  reaction  is  negative  they  are  dissolved,  forming  a  clear  crimson 
solution.  Numerous  controls  are  necessary,  but  exact  details  of  this  (the 
original)  process  will  not  be  given,  since  it  can  only  be  carried  out  by  an 
experimenter  having  facilities  for  the  use  of  animals.  Some  simpler 
methods,  which  are  not  beyond  the  reach  of  independent  workers,  will 
be  given. 

The  most  important  modification  consists  in  the  replacement  of  the 
extract  described  above  by  an  alcoholic  extract  of  a  syphilitic  liver  or 
of  a  normal  heart— either  human,  or  from  a  guinea-pig  or  ox.  A  con- 
venient method  is  to  take  a  few  grammes  of  normal  heart-muscle,  add 
five  times  its  weight  of  absolute  alcohol,  grind  the  two  together  and  allow 
it  to  macerate  for  twenty-four  hours.  Then  heat  the  mixture  to  60°  C. 
for  one  hour  and  filter,  and  the  extract  is  ready.  For  use  dilute  one  part 
of  the  clear  solution  with  nine  parts  or  more  of  normal  saline  solution,  the 
exact  degree  of  dilution  necessary  for  any  given  sample  being  determined 
by  experiments  with  normal  and  syphilitic  sera.  The  alcoholic  solution 
keeps  indefinitely,  but  usually  undergoes  alterations  in  strength.  Not 
all  extracts  act  equally  well,  and  none  should  be  admitted  for  clinical 
use  until  it  has  been  used  for  numerous  tests  on  known  bloods,  syphilitic 
and  non-syphilitic. 

It  may  be  pointed  out  that  the  fact  that  an  alcoholic  solution  of  a 
normal  organ  acts  as  an  antigen  in  the  test  proves  that  the  reaction 
is  not  in  reality  on  a  par  with  the  Bordet-Gengou  reaction,  as  described 
above.  It  was  necessary  to  describe  that  reaction  in  order  to  explain 
what  happens  in  the  Wassermann  test,  but,  as  a  matter  of  fact,  the  latter 
is  at  present  purely  empirical.  Its  practical  value  is  proved  by  clinical 
experience,  but  the  theoretical  considerations  which  led  to  its  intro- 
duction are  unsound,  and  at  the  time  of  writing  we  do  not  know  in  the 
least  how  the  complement  is  absorbed  in  a  positive  reaction. 

The  simplest  modification  is  that  introduced  by  Hecht  and  advocated 
by  Fleming.  It  depends  on  the  fact  that  normal  human  serum  usually 
contains  amboceptor  and  complement  for  sheep's  corpuscles.  It  is 
carried  out  as  follows  :  The  blood  to  be  tested  is  collected  in  the  ordinary 
way  in  Wright's  pipettes,  allowed  to  clot  and  centrifugalised,  so  that 
clear  serum  is  obtained.  With  a  fine  pipette  i  unit  (of  about  ten  cubic 
millimetres)  of  this  fresh  serum  is  placed  in  a  narrow  tube  (about  Jth  in. 
wide)  and  mixed  with  4  units  of  diluted  alcoholic  extract,  prepared  as 
above.  A  second  tube  is  prepared,  in  which  the  extract  is  replaced  by 
normal  saline  solution  :  this  is  an  absolutely  necessary  control.  No  com- 
plement is  added,  that  present  in  the  serum  itself  being  sufficient.  The 
two  tubes  are  incubated  for  an  hour,  and  then  I  unit  of  a  10  per  cent. 
emulsion  of  sheep's  corpuscles,  which  have  been  washed  by  at  least  three 
centrifugalisations  from  normal  saline  solution,  is  added  and  well  mixed 


512 


EXAMINATION  OF  THE  BLOOD 


in.  The  mixtures  are  returned  to  the  incubator  for  two  hours ;  it  is  an 
advantage  to  stir  or  shake  them  from  time  to  time.  They  are  then 
allowed  to  settle.  In  a  positive  reaction  the  first  tube  will  show  no 
haemolysis,  whereas  in  the  second  the  haemolysis  will  be  complete ;  in  a 
negative  one  each  tube  will  show  complete  haemolysis,  and  not  infre- 
quently it  happens  that  there  is  no  haemolysis  in  either  tube.  This  shows 
that  this  method  is  unavailing  and  another  process  must  be  used.  The 
results  may  be  given  in  tabular  form  thus  : — 


Positive 
reaction 

Negative 
reaction 

Indeterminate 

/Serum  i  part 
'\Extract  4  parts 

f  Serum  i  part 
2.  <  Normal  saline 
C     4  parts 

Incubated  i  hour 
and  i  unit  emul- 
sion  sheep's 
i    corpuscles 
added 

No 
haemolysis 

Haemolysis 

No 

haemolysis 

Haemolysis 

Haemolysis 

No 
haemolysis 

Numerous  controls  ought  to  be  added,  e.g.  tubes  containing  4  units  of 
extract  and  of  normal  saline,  but  no  serum ;  the  serum  from  a  known 
syphilitic  and  a  known  non-syphilitic  person,  which  ought  to  react  as 
theory  demands. 

Sheep's  corpuscles  are  not  always  easy  to  obtain,  and  to  avoid  this 
difficulty  the  author  of  this  article  uses  the  following  method,  based  on  a 
process  introduced  by  Tschernagubow,  but  rather  more  convenient  in 
detail.  The  corpuscles  used  are  human  ones,  well  washed  by  repeated 
centri  fugalisations  (at  least  three)  from  normal  saline  solution.  Apart 
from  these  and  the  extract,  the  only  requisite  is  heated  serum  from  a 
rabbit  which  has  been  injected  with  human  corpuscles  and  thus  contains 
an  antibody  to  these  structures.  This  serum  keeps  well,  and  can  be 
put  up  in  ampoules  in  quantities  sufficient  for  a  number  of  tests,  so  as 
to  be  always  at  hand.  The  earlier  part  of  the  process  is  exactly  the 
same  as  in  Fleming's  method.  After  the  first  incubation  i  unit  of  a 
mixture  of  i  volume  of  washed  human  corpuscles  and  4  parts  of  immune 
serum  (previously  mixed  and  allowed  to  stand  for  ten  minutes,  so  that 
the  corpuscles  may  be  fully  sensitised)  is  added,  and  the  mixture  re- 
incubated  as  before.  In  a  positive  reaction  the  complement  is  absorbed 
in  the  first  incubation,  and  there  is  no  haemolysis.  In  a  negative  one  it  is 
not  absorbed,  and  dissolves  the  corpuscles,  which  are  sensitised  by  means 
of  the  rabbit  serum.  The  results  are  the  same  as  those  shown  on  the 
preceding  table,  except  that  there  are  no  indeterminate  results,  the 
conditions  for  haemolysis  being  always  present  unless  the  complement 
has  been  absorbed  in  a  positive  reaction.  This  method  is  extremely 
simple  and  appears  to  give  very  good  results. i 

1  For  fuller  details,  see  Lancet,  September  3,  1910. 


THE  WASSERMANN  REACTION  5I3 

Wassermann's  reaction  usually  makes  its  appearance  during  or  at 
the  end  of  the  primary  stage  of  the  disease  :  approximately  half  the  cases 
give  a  reaction  before  the  appearance  of  the  secondary  symptoms.  In 
the  secondary  stage  it  is  almost  constant— in  fact,  some  observers  have 
actually  obtained  100  per  cent,  of  positive  results,  although  in  most  series 
there  are  a  few  negative  findings  in  undoubted  cases.  Subsequently  to  this, 
much  depends  on  the  efficacy  with  which  the  case  has  been  treated.  As 
long  as  the  disease  is  causing  actual  clinical  manifestations,  the  reaction 
persists,  and  the  same  is  true  if  it  is  merely  lying  latent.  When,  however, 
the  patient  has  had  a  thorough  course  of  treatment  and  the  disease  is 
completely  eradicated,  then  the  reaction  disappears.  According  to  some 
observers  vigorous  treatment  may  cause  the  reaction  to  disappear,  but 
without  accomplishing  a  complete  cure,  as  shown  by  the  fact  that  it 
may  reappear  after  a  few  weeks'  cessation  of  the  treatment.  In  fact, 
the  mere  presence  of  mercury  in  the  blood  may  abolish  (temporarily) 
a  positive  reaction. 

A  positive  reaction  is  known  to  occur  occasionally  in  diseases  other 
than  syphilis,  but  the  conditions  under  which  it  does  so  are  not  ascer- 
tained at  present.  It  appears  to  be  present  frequently  in  leprosy  and  in 
some  tropical  diseases  due  to  protozoa  (framboesia,  sleeping  sickness). 
Apart  from  this  it  has  been  described  as  occurring  in  other  diseases,  such 
as  scarlet  fever  (but  not  constantly,  and  only  for  a  short  time)  ;  but  many 
of  these  results  were  obtained  in  the  early  days,  before  the  technique  of  the 
reaction  had  been  fully  worked  out.  At  the  present  time  it  is  extremely 
rare  to  find  a  positive  reaction  in  a  case  in  which  syphilis  can  be  excluded. 

Hence  the  following  rules  for  the  interpretation  of  the  Wassermann 
reaction  may  be  given  : — 

(1)  In  the  (supposed)  primary  stage  a  positive  reaction  is  conclusive 
of  syphilis  :    a  negative  reaction  is  inconclusive,  but  is  more  and  more 
suggestive  the  longer  the  doubtful  lesion  has  been  present. 

(2)  In  the  (supposed)  secondary  stage  again  a  positive  reaction  is  con- 
clusive :   a  negative  reaction  renders  the  diagnosis  extremely  improbable, 
except  in  the  very  early  stages. 

(3)  In  the  later  stages,  if  there  are  active  clinical  manifestations,  there 
will  almost  certainly  be  a  positive  reaction  :    hence  if  a  patient  with  a 
supposed  gumma  react  negatively  the  diagnosis  is  probably  wrong. 

(4)  The  presence  of  the  reaction  is  always  an  indication  to  continue 
treatment.     The  absence  of  a  reaction,  especially  if  it  occurs  on  several 
occasions  at  intervals  of  a  few  weeks  and  after  mercurial  treatment  has 
been  suspended  for  at  least  three  months,  indicates  that  the  disease  is 
completely  eradicated. 

(5)  Congenital  cases  react  like  acquired  ones,  and  the  reaction  may 
persist  into  adult  life. 


L  L 


514  EXAMINATION   OF  THE  BLOOD 


PREPARATION  OF  VACCINES. 

As  a  general  rule  the  use  of  a  vaccme  prepared  from  cultures  derived 
from  the  pus  or  other  morbid  material  of  the  patient  to  be  treated  will  be 
found  to  give  better  results  than  a  stock  vaccine  ;  this  is  especially  the 
case  with  organisms  such  as  streptococci,  gonococci  and  B.  coli,  which 
differ  widely  amongst  themselves.  In  other  cases,  such  as  infections 
with  staphylococci  and  pneumococci,  the  need  is  not  so  great,  and 
treatment  may  well  be  commenced  with  a  stock  vaccine  made  from 
several  strains  of  the  organism.  But  if  this  fails  the  vaccine  treatment 
should  not  be  condemned  until  an  autochthonous  vaccine  has  been  used. 

The  method  by  which  these  vaccines  are  prepared  is  not  difficult, 
though  it  is  somewhat  tedious  and  requires  the  closest  attention  to  details, 
more  especially  in  regard  to  those  necessary  to  ensure  sterility  of  the  final 
product.  The  following  is  the  process  usually  employed. 

Preparation  of  the  Culture. — This  is  made  from  the  pus,  blood, 
etc.,  on  ordinary  bacteriological  lines,  and,  in  general,  agar  is  used  as  the 
culture  medium  :  additions  such  as  that  of  sterile  blood  in  the  case  of  the 
gonococcus  being  made,  when  necessary,  to  adapt  it  to  the  requirements  of 
the  particular  organism.  It  is  desirable,  if  possible,  to  use  the  primary 
culture,  since  many  bacteria  lose  their  virulence  rapidly  when  cultivated 
on  artificial  media,  and  virulence  of  the  culture  is  an  essential  factor  for 
a  good  vaccine.  If  the  primary  culture  (i.e.  that  inoculated  with  the 
material  from  the  patient)  is  not  pure,  a  second  one  is  inoculated  from 
colonies  of  the  organism  in  question :  it  is  advisable  not  to  make  this 
second  culture  from  a  single  colony,  since  organisms  vary  greatly  amongst 
themselves,  even  in  a  pure  culture,  and  it  might  happen  that  the 
colony  selected  was  one  of  a  relatively  non-virulent  form.  When  time  is 
an  object  the  primary  culture  may  be  used,  even  if  not  quite  pure,  pro- 
vided that  the  organisms  are  non-spomlating  (and  so  easy  to  kill)  and  non- 
pathogenic  or  of  feeble  pathogenicity.  A  few  colonies  of  staphylococci, 
the  most  common  contamination,  do  not  interfere  with  the  use  of  the 
vaccine  at  all,  except  in  regard  to  the  dosage. 

The  culture  should  be  as  young  as  possible.  In  the  case  of  rapidly 
growing  organisms  such  as  staphylococci  and  B.  coli,  cultures  18-24  hours 
old  should  be  used.  In  dealing  with  organisms  such  as  gonococci,  which 
grow  more  slowly,  older  cultures  must  necessarily  be  used,  but  in  no  case 
should  incubation  be  continued  when  a  good  growth  has  developed. 

Preparation  of  the  Emulsion. — One  to  ten  cubic  centimetres  of  sterile 
normal  saline  solution  (the  exact  amount  is  not  of  importance)  is  added  to 
the  agar  culture  by  means  of  a  sterile  pipette,  and  the  growth  scraped  off 
with  a  sterile  platinum  loop.  The  emulsion,  thus  formed,  is  shaken 
gently  so  as  to  break  up  the  colonies  as  far  as  possible,  and  allowed  to 
stand  for  a  few  minutes  so  that  any  large  masses  may  settle.  The  saline 


PREPARATION  OF  VACCINES  515 

solution  must  be  absolutely  sterile.  If  an  autoclave  is  at  hand,  it  should  be 
raised  to  120°  C.  for  half  an  hour.  Reliance  on  mere  boiling  is  unwise, 
unless  the  water  used  in  the  preparation  of  the  saline  solution  is  known  to 
be  free  from  sporulating  bacteria,  as  is  usually  the  case  with  the  water- 
supply  of  most  English  towns. 

The  emulsion  thus  prepared  is  pipetted  with  a  sterile  pipette  into  a 
sterilised  test-tube,  thoroughly  shaken,  and  the  sample  required  for 
counting  purposes  removed.  The  bulk  of  the  vaccine  is  then  sterilised. 

Sterilisation  of  the  Vaccine. — The  middle  of  a  sterile  test-tube  is 
thoroughly  softened  in  the  flame,  and  the  two  ends  are  pulled  apart  so  that 
the  softened  portion  is  drawn  out  to  form  a  narrow  tube  about  Jth  in.  in 
diameter.  It  is  allowed  to  cool,  and  the  emulsion  is  poured  in,  and  got 
into  the  lower  portion  of  the  tube  by  alternately  warming  and  cooling  the 
latter,  so  as  to  expand  and  contract  the  air  which  it  contains.  The  narrow 
portion  of  the  tube  is  now  sealed  in  the  flame,  and,  when  cool,  the  bulb 
containing  the  vaccine  is  inverted  and  warmed  in  the  hand,  so  as  to  make 
sure  that  the  seal  is  a  sound  one,  no  fluid  being  expelled  :  if  a  drop  comes 
out  the  tip  must  be  resealed. 

This  hermetically  sealed  tube  of  vaccine  is  now  attached  to  a  weight 
and  completely  immersed  in  a  water-bath  kept  at  60°  C.  If  a  thermo- 
stat at  this  temperature  is  not  at  hand  a  large  beaker  of  water  will  answer 
perfectly,  the  desired  temperature  being  maintained  by  the  application 
and  removal  of  a  small  flame,  such  as  that  of  a  spirit  lamp.  In  this  case  it 
is  a  good  plan  to  attach  the  tube  of  vaccine  to  the  bulb  of  the  thermometer 
by  means  of  an  indiarubber  band,  of  course  taking  care  that  no  part  of  the 
former  is  out  of  the  water. 

The  period  of  heating  is  usually  one  hour.  Some  organisms  are  killed 
more  quickly  than  this,  but  it  is  well  to  be  on  the  safe  side  until  some 
experience  is  attained  as  to  the  amount  of  heat  necessary  in  the  case 
of  the  organism  in  use.  In  general  the  less  the  vaccine  is  heated  the  better, 
provided  it  is  sterile. 

Counting  the  Emulsion. — While  the  tube  is  being  heated  the  pre- 
parations, which  should  have  been  made  at  an  earlier  stage,  may  be  counted 
and  the  calculations  made.  The  methods  of  counting  or  otherwise 
determining  the  richness  of  the  emulsion  are  numerous,  but  here  only  Sir 
Almroth  Wright's  will  be  described.  It  consists  in  comparing  the  number 
of  bacteria  in  the  vaccine  with  the  number  of  red  corpuscles  in  human 
blood,  this  having  been  previously  estimated  by  means  of  the  haemocyto- 
meter.  Numerous  slight  modifications  of  the  process  are  in  use,  and 
that  given  will  be  found  efficacious. 

A  Wright's  pipette,  such  as  is  used  in  the  determination  of  the  opsonic 
index,  is  prepared  by  softening  the  centre  of  a  piece  of  glass  tubing  in  the 
flame  and  drawing  it  out  into  a  tube  about  as  thick  as  a  steel  knitting- 
needle,  or  rather  thinner.  This  is  broken  in  the  centre,  so  as  to  give  t\\<> 
capillary  pipettes  each  attached  to  a  wider  portion  of  tubing,  on  which 

LI.  2 


5i6  EXAMINATION   OF  THE  BLOOD 

an  india-rubber  nipple  is  slipped.  A  unit  mark  is  made  with  grease- 
pencil  about  i  inch  from  the  tip  and  the  apparatus  is  ready  for  use.  The 
operator  then  winds  a  narrow  bandage  round  one  of  the  fingers  of  his 
left  hand  so  as  to  congest  the  tip,  and  makes  a  small  puncture  with  the 
sharp  point  of  a  piece  of  capillary  tubing  just  drawn  out  in  the  flame  and, 
therefore,  sterile.  By  bending  the  finger  a  drop  of  blood  is  squeezed  out,  and 
enough  of  this  to  reach  exactly  to  the  unit  mark  is  sucked  into  the  pipette. 
This  is  withdrawn  from  the  blood  and  a  little  air  sucked  in.  The  emulsion 
is  well  shaken  and  this  also  is  sucked  up  to  the  unit  mark  in  the  tube,  thus 
giving  exactly  equal  amounts  of  the  two  fluids.  These  are  expelled  on 
to  the  surface  of  a  clean  slide  and  thoroughly  mixed.  Films,  which  must 
be  thin  and  even,  are  prepared  from  the  mixture  :  there  must  be  no  delay 
about  this,  or  the  blood  may  coagulate.  These  films  must  then  be  fixed 
and  stained  by  some  method  which  will  show  both  the  bacteria  and  the 
red  corpuscles  :  Jenner's  method  may  be  used,  but  it  is  better  to  fix  with 
a  saturated  solution  of  perchloride  of  mercury  and  stain  with  carbol- 
fuchsin. 

These  films  are  then  examined  microscopically  and  a  count  is  made  of 
the  number  of  red  corpuscles  and  of  bacteria  seen  in  the  same  field  of 
the  microscope.  It  is  necessary  to  count  many  of  these  fields  (since  the 
spreading  is  never  quite  even),  so  that  a  reasonably  accurate  estimation  of 
the  ratio  of  the  two  objects  may  be  obtained :  and  these  fields  should 
be  taken  from  all  regions  of  the  film. 

The  calculation  of  the  number  of  bacteria  in  the  emulsion  is  then 
simple.  Thus  supposing  20  fields  were  counted  and  found  to  contain 
720  red  corpuscles  and  200  bacteria,  and  then,  having  found  that  the 
blood  contains  5,200,000  red  corpuscles  per  cubic  millimetre,  the  calcula- 
tion is  as  follows  : — 

For  each  red  corpuscle  there  is  f-f  $  bacteria. 

i  cubic  millimetre  of  blood  contains  5,200,000  corpuscles. 
.  • .  i  cubic  millimetre  of  emulsion  contains  5,200,000  X  ff$  bacteria 

=  1,400,000  (about) 
And  i  cubic    centimetre    contains    1,400,000,000. 

If  it  was  desired  to  prepare  a  vaccine  containing  100  millions  per  cubic 
centimetre  it  would  be  diluted  with  thirteen  times  its  volume  of  diluent. 
If  1000  millions  were  required  in  one  cubic  centimetre,  then  ten  volumes 
of  the  emulsion  would  have  to  be  diluted  with  four  volumes  of  diluent, 
and  so  on. 

Testing  the  Sterility  of  the  Emulsion. — The  hour  having  elapsed  the 
bulb  of  vaccine  is  removed  from  the  fluid,  and  the  tip  is  sterilised  in  the 
flame  and  broken  off  with  a  pair  of  sterile  forceps.  A  little  of  the  fluid 
is  then  expelled  on  to  the  surface  of  agar  or  other  suitable  medium,  and 
the  culture  tube  replugged  and  incubated.  Unless  it  remains  sterile  the 
vaccine  must  not  be  used. 


SUGGESTIONS  FOR  DOSAGE  OF  VACCINES  517 

In  cases  of  great  urgency  the  experienced  bacteriologist,  who  is  sure  of 
his  technique,  may  omit  this  step  in  the  case  of  some  organisms,  and  thus 
shorten  the  process  by  twenty-four  hours  or  more. 

Preparing  the  Dilutions. — The  emulsion  is  diluted  with  normal  saline 
solution,  containing  a  certain  amount  of  some  antiseptic,  of  which  carbolic 
acid  seems  to  answer  best.  Its  strength  will  vary  according  to  the  amount 
to  be  added  to  a  given  volume  of  the  vaccine,  so  that  the  final  product 
should  contain  £•-•£  per  cent.  Thus  in  the  example  given,  if  the  emulsion 
were  to  be  diluted  thirteen  times,  J  per  cent,  would  be  used  for  the  diluent. 
In  the  second  case,  where  four  volumes  were  to  be  added  to  10  per  cent,  of 
the  emulsion,  the  fluid  used  might  contain  i  per  cent,  of  carbolic  acid  to 
start  with,  giving  a  final  strength  in  the  vaccine  of,  roughly,  J  per  cent. 
These  dilutions  are  made  in  sterile  test-tubes,  and  the  amounts  may  be 
conveniently  measured  by  the  use  of  an  ordinary  all-glass  hypodermic  or 
exploring  syringe.  The  vaccine  is  now  finished.  It  may  be  kept  in  bulk 
in  sterile  test-tubes  or  bottles,  or,  preferably,  may  be  put  up  in  sealed 
bulbs  or  ampoules,  each  containing  one  dose.  A  hypodermic  syringe 
may  be  used  for  filling  these  bulbs,  which  are  then  hermetically  sealed 
in  the  flame. 


SUGGESTIONS  FOR  DOSAGE  OF  VACCINES. 

The  following  suggestions  are  offered  as  a  rough  guide  as  to  the  dosage 
of  vaccines,  in  case  no  opsonic  control  is  used.  As  a  general  rule  the  doses 
will  be  smaller  in  the  more  acute  and  severe  cases,  larger  in  the  chronic 
ones ;  where  very  small  doses  are  given  the  interval  between  them  may 
be  less  than  if  large  doses  are  employed,  and  in  any  case  the  clinical 
symptoms  must  be  closely  watched,  so  that  any  indication  as  to  size 
of  doses  and  length  of  interval  may  be  obtained. 

Staphylococci.—Dose  250-1000  millions  at  intervals  of  10-14  days. 
Some  give  smaller  doses,  but  they  are  probably  not  so  efficacious. 

Streptococci.— In  septicaemia,  erysipelas,  and  other  acute  and  severe 
infections  5-25  millions  every  4-7  days.  In  more  chronic  cases  the  dose 
should  be  small  to  commence  with,  but  may  go  up  to  100  millions  or  even 

more. 

The  use  of  anti-streptococcic  serum  must  not  be  forgotten. 

Pneumococci.— In  acute  cases  5-25  millions  may  be  given  every  4-7 
days,  or  of tener,  if  the  clinical  signs  seem  to  justify  it.  In  chronic  cases  the 
dose  may  gradually  rise  to  250  millions  or  even  higher,  and  the  injections 
be  made  every  7-10  days. 

Gonococci—  Good  results  have  been  obtained  in  ordinary  gonor 
as  the  result  of  one  or  two  doses  of  10-50  millions  :    there  is  a  general 
tendency  towards  a  reduction  of  the  dosage.     In  the  vulvo-vaginitis  of 
children  the  dose  should  be  1-5  millions.      In  gonorrhceal  arthritis  it  is 


5i8  EXAMINATION  OF  THE  BLOOD 

usually  advisable  to  increase  the  dose  up  to  500  millions  or  even  more  : 
5  or  10  millions  may  be  given  to  commence  with,  and  successive  doses 
given  every  7-10  days. 

Bacillus  coli. — The  initial  dose  may  be  25-50  millions,  increasing  to  250 
millions  at  intervals  of  7-10  days,  or  as  the  clinical  signs  suggest,  though, 
as  a  rule,  not  oftener.  The  use  of  a  vaccine  prepared  from  the  patient 
himself  is  usually  necessary. 

When  an  unknown  or  unrecognised  organism  is  isolated  from  a  lesion 
(as  is  not  very  infrequently  the  case),  it  is  necessary  to  proceed  with 
caution  as  the  bacterium  may  be  a  very  irritating  one  and  a  very  small 
dose  only  advisable.  It  is  best  to  give  not  more  than  5  millions  to  com- 
mence with.  If  there  is  no  local  or  general  reaction  within  twenty-four 
hours  a  larger  dose,  say  25  millions,  may  be  given. 

THE  DIAGNOSIS  OF  BACTERIAL  INFECTIONS  BY  MEANS 
OF  THE  OPSONIC  INDEX. 

When  the  last  edition  of  this  work  was  issued  it  was  generally  thought 
that  useful  information  as  to  the  dosage  of  vaccines  and  of  tuberculin 
might  be  obtained  by  periodical  observations  of  the  opsonic  index,  i.e., 
the  power  of  the  serum  of  the  patient  to  aid  phagocytosis  as  compared 
with  that  of  a  normal  person  acting  under  the  same  conditions.  This 
idea  is  now  almost  abandoned.  The  estimation  of  the  opsonic  index 
is,  however,  useful  at  times  in  the  diagnosis  of  bacterial  infections  in 
which  it  is  impossible  to  obtain  material  from  which  the  infecting 
organisms  can  be  obtained  and  identified.  The  method  used  for  the 
estimation  of  the  index  is  that  given  by  Dr.  Whitfield  in  the  last  edition, 
with  one  or  two  alterations. 

Method  of  Observation. — Normal  blood  from  any  individual  is  dropped 
from  a  prick  in  the  finger  into  a  vessel  containing  6-5  per  cent,  sodium 
citrate  in  normal  saline.  This  is  then  centrifugalised  so  that  the  corpuscles 
washed  free  of  their  serum  lie  at  the  bottom,  the  top  layer  of  the  deposit 
being  rich  in  leucocytes.  It  is  advisable  to  mix  the  deposit  with  normal 
saline  and  to  repeat  the  centrifugalisation,  so  that  all  trace  of  serum 
may  be  removed.  About  a  quarter  of  the  deposit  is  then  drawn  off  and 
thoroughly  mixed  up,  so  that  there  may  be  a  fairly  even  distribution 
of  the  leucocytes  contained  in  it.  This  mass  of  red  blood  corpuscles 
rich  in  leucocytes  is  habitually  spoken  of  as  '  leucocytic  cream.'  Secondly, 
a  sample  of  blood  from  the  patient  to  be  examined  is  allowed  to  clot 
and  the  clear  serum  is  drawn  off.  As  a  matter  of  fact  this  sample 
is  generally  taken  some  hours  beforehand  in  order  to  get  the  serum. 
Thirdly,  an  emulsion  is  made  of  the  bacillus  in  question.  Equal  quantities 
of  thsse  are  taken  in  a  pipette,  thoroughly  mixed  and  then  incubated 
at  blood  heat  for  twenty  minutes.  The  mixture  is  then  blown  out  of 
the  pipette  and  again  mixed,  and  film  preparations  are  made  from  it 


THE  DIAGNOSIS  OF  BACTERIAL  INFECTIONS        519 

and  appropriately  stained.  At  least  a  hundred  leucocytes  are  then 
counted  and  the  number  of  bacilli  ingested  by  each  is  noted,  so  that 
an  average  may  be  worked  out  of  the  number  of  bacilli  ingested  by  a 
leucocyte.  This  is  then  compared  with  the  number  obtained  in  an 
exactly  similar  experiment  carried  out  with  serum  of  a  person  known 
to  be  of  the  normal  standard,  and  the  result  expressed  as  a  decimal 
fraction  of  that  which  is  taken  as  the  normal.  Thus  a  patient  suffering 
from furunculosis  maybe  found  to  have  an  opsonic  index  of  o-5 to  staphy- 
lococci  though  he  may  have  an  index  of  i-o  to  tubercle  bacilli.  It  is 
necessary  that  a  normal  control  be  worked  out  with  each  set  of  sera  to 
be  tested,  as  the  bacillary  emulsion  cannot  be  made  a  constant  factor, 
and  probably  the  leucocytes  also  vary  in  activity,  so  that  it  is  only  by 
using  the  same  '  cream '  and  the  same  emulsion  that  accuracy  can  be 
obtained.  The  leucocyte  cream  should  be  used  as  fresh  as  possible,  in 
order  that  the  leucocytes  may  be  alive  and  active,  but  this  will  last  at 
least  an  hour  and  probably  much  more. 

The  method  is  especially  useful  in  the  diagnosis  of  tuberculosis,  in 
cases  in  which  it  is  impossible  to  obtain  material  in  which  a  search  for 
the  bacillus  can  be  made,  and  in  which  the  other  methods  of  diagnosis 
which  depend  on  hypersensitiveness  to  tuberculin  are  contra-indicated. 
In  general  terms  it  may  be  stated  that  the  range  of  the  opsonic  index 
to  tubercle  in  healthy  persons  or  in  persons  suffering  from  disease  other 
than  tuberculosis  is  between  O'8  and  1*2,  as  compared  with  the  average 
of  normal  persons,  taken  as  I.  Indices,  therefore,  which  lie  between 
these  figures  are  inconclusive  one  way  or  the  other.  Indices  which 
lie  above  or  below  these  limits  raise  a  presumption  that  the  disease 
is  tuberculosis,  and,  the  further  they  are  removed  from  the  normal,  the 
more  trustworthy  is  the  diagnosis  :  thus,  an  index  of  075  would  be 
suspicious  only,  whereas  one  of  0-5  would  be  practically  conclusive,  and 
the  same  is  true  for  indices  of  1*25  and  1/5  respectively. 

When  the  index  lies  between  the  normal  limits  and  yet  the  diagnosis 
of  tubercle  seems  probable,  advantage  can  be  taken  of  the  fact  that 
a  minute  injection  of  tuberculin,  not  enough  to  cause  an  obvious  reaction, 
or  massage  of  the  area  of  the  lesion  (which  is  supposed  to  cause  '  auto- 
inoculation  '  and  let  loose  some  tuberculous  products)  causes  more  or 
less  characteristic  alterations  of  the  opsonic  index,  which  usually  falls 
and  then  rises  to  a  higher  level  than  that  at  which  it  stood  previously. 
To  make  use  of  this  test  a  series  of  observations  of  the  index  must  be 
taken,  and  the  effect  of  one  of  the  procedures  mentioned  studied.  If  the 
index  remains  practically  constant  throughout,  a  diagnosis  of  tubercle  is 
unlikely  :  if  it  varies  greatly,  and  especially  if  a  '  negative  phase  ' 
followed  by  a  rise  occurs,  the  patient  is  probably  tuberculous.  It  is 
claimed  that  this  method  will  enable  the  observer  to  say  that  a  lesion 
which  was  known  to  be  tuberculous  is  cured  :  if  the  index  remains 
constant  in  spite  of  massage  or  of  use,  it  is  supposed  that  the  bacilli  in 


520  EXAMINATION   OF  THE  BLOOD 

the  region  are  destroyed  or  are  at  least  no  longer  in  a  state  to  produce 
toxins. 

The  opsonic  index  can  also  be  used  to  diagnose  infections  other  than 
tuberculosis.  The  index  of  the  serum  is  worked  out  against  cultures 
of  the  organisms  which  experience  shows  are  probably  concerned, 
and  that  with  which  the  serum  deviates  most  from  the  normal  figure  is 
found.  Or  a  series  of  indices  may  be  taken  before  and  after  massage 
or  exertion  of  the  affected  part  of  the  body,  cultures  of  all  the  likely 
bacteria  being  used.  It  is  undoubtedly  possible  to  diagnose  the  causative 
organism  in  this  way,  but  the  labour  is  great.  Further — and  this  is  a 
point  which  must  be  constantly  borne  in  mind  in  interpreting  the  results 
of  opsonic  determinations — the  process  is  a  most  difficult  one,  and  requires 
much  patience  and  a  great  amount  of  technical  skill  for  its  successful 
performance.  For  this  reason  opsonic  methods  should  only  be  used 
when  the  diagnosis  cannot  be  made  otherwise,  and  it  is  of  vital  importance 
that  the  nature  of  the  disease  should  be  recognised  at  once.  In  children 
(up  to  the  age  of  fourteen  years)  the  cuti-reaction  or  von  Pirquet's 
reaction,  is  in  every  way  preferable,  whilst  in  adults  there  are  few  cases  in 
which  the  subcutaneous  injection  of  old  tuberculin  will  not  give  results 
which  are  much  more  certain  and  which  are  obtained  more  quickly,  and 
with  a  minimum  amount  of  risk. 


TUBERCULIN  IN  DIAGNOSIS. 

Tuberculin,  after  a  long  period  of  disuse  (in  this  country  at  least) 
has  recently  rapidly  gained  favour  both  as  a  diagnostic  and  as  a  thera- 
peutic agent.  This  is  largely  owing  to  a  fuller  knowledge  of  the  substance 
and  its  action,  and  partly  also  to  the  discovery  of  new  methods  in  which 
it  can  be  employed.  It  is  now  realised  that,  given  proper  care,  tuber- 
culin can  be  used  in  diagnosis  without  danger,  and  yields  results  which 
are,  in  many  cases,  absolutely  accurate. 

In  children  the  most  useful  diagnostic  method  is  that  based  on  the 
fact  (discovered  by  von  Pirquet)  that  the  application  of  old  tuberculin  to 
the  skin  of  tuberculous  patients  causes  a  local  inflammatory  reaction 
which  may  go  on  to  vesiculation  ;  whereas  in  normal  or  non-tuberculous, 
persons  it  has  no  such  action.  This  is  called  the  cuti-reaction  or  von 
Pirquet's  reaction.  It  is  carried  out  much  in  the  same  way  as  an  ordinary 
calf-lymph  vaccination,  old  tuberculin,  preferably  undiluted,  being 
used  instead  of  the  lymph.  An  area  about  a  quarter  of  an  inch  in 
diameter  is  lightly  scarified  by  any  suitable  instrument,  which  should 
not  be  too  sharp :  the  object  is  to  remove  the  surface  epithelium  down 
to  the  corium,  but  not  to  draw  blood.  A  drop  or  two  of  old  tuberculin 
is  rubbed  well  into  this  area  and  allowed  to  soak  in.  It  is  important 
that  it  should  not  be  rubbed  off  before  this  has  happened,  and  it  is  a  good 


TUBERCULIN   IN   DIAGNOSIS  521 

plan  to  protect  the  area  with  a  vaccination  shield  or  watch-glass  (applied 
with  strapping)  for  an  hour  or  so.  It  is  advisable,  but  not  absolutely 
necessary,  to  perform  a  control  scarification,  using  equal  parts  of  glycerine 
and  water  instead  of  the  tuberculin.  In  a  negative  case  little  or  nothing 
will  he  seen  in  either  area  next  day.  If  a  positive  reaction  occurs,  the 
area  to  which  tuberculin  has  been  applied  will  become  more  or  less 
severely  inflamed.  In  the  mildest  grade  of  reaction  there  is  redness 
and  swelling  of  the  scarified  area,  which  appears  as  a  flat  red  papule. 
In  the  next  grade  these  appearances  are  not  limited  to  the  area  to  which 
the  tuberculin  has  been  applied,  but  spread  for  some  distance  in  all 
directions.  In  the  most  severe  reactions  there  is,  in  addition  to  this, 
vesiculation  of  the  area  scarified  ;  the  control  inoculation  should  show 
practically  nothing. 

The  reaction  is  almost  absolutely  trustworthy  in  children  up  to  the 
age  of  twelve  or  fourteen,  the  only  exception  being  in  those  suffering 
from  general  tuberculosis  or  tuberculous  meningitis,  in  whom  the  tuber- 
culous infection  may  be  so  severe  that  the  reacting  power  is  lost :  in 
my  experience  this  rarely  happens  until  so  late  in  the  disease  that  the 
diagnosis  is  not  for  a  moment  in  doubt.  The  reason  why  the  test  is  not 
satisfactory  in  older  people  is  that  tuberculous  infections  of  a  mild  and 
latent  type  are  extremely  common  in  early  life,  and  they  appear  to 
sensitise  the  tissues  for  many  years  after  they  are  completely  healed. 
But  a  very  marked  reaction  usually  indicates  a  recent  infection,  even 
in  an  adult. 

Other  forms  of  applying  the  test,  such  as  Calmette's,  in  which  diluted 
tuberculin  is  dropped  on  to  the  conjunctiva,  where  it  causes  a  con- 
junctivitis, mild  in  the  majority  of  cases,  but  sometimes  very  severe, 
are  in  use.  They  are  not  to  be  recommended,  and  Calmette's  test  (though 
it  gives  good  results  as  regards  the  diagnosis)  should  not  be  employed 
because  of  the  danger  to  sight  which  it  entails. 

The  diagnostic  use  of  tuberculin  by  subcutaneous  injection  should  be 
reserved  for  those  cases  in  which  the  cuti-reaction  is  inapplicable,  and 
in  which  no  morbid  material  in  which  a  search  for  tubercle  bacilli  can  be 
conducted  can  be  obtained.      Using  small  doses  it  is  probably  devoid 
of  danger  except  in  cases  with  severe  secondary  infections,  especially 
in  phthisis.     In  surgical  affections  it  may,  as  a  rule,  be  applied  without 
hesitation  except  perhaps  in  cases  of  deep  sinuses  and  abscesses  con- 
taminated with  bacteria  other  than  the  tubercle    bacillus.     It    shoul 
not  be  used  where  the  temperature  is  irregular,  nor  in  cases  where  t 
has  recently  been  hemoptysis.     Cardiac  and  renal  diseases  are  als 
considered  to  be  contra-indications. 

As  regards  dosage,  there  is  as  yet  no  uniformity  of  opinion,  but 
general   tendency  has  been  to  reduce  the  amount  given  and  to  g 
several   injections    of   gradually   increasing   doses.     My   own    practice 
is  to  begin  with  ^Vo  c-c.  of  old  tuberculin,  and,  if  this  causes  no  reaction, 


522  EXAMINATION   OF  THE  BLOOD 

to  go  at  once  to  -^G  or  3-^0  c-c->  an(^  to  regard  anything  as  negative  in 
which  there  is  no  reaction  after  this  amount.  Most  recent  writers  give 
somewhat  less  than  this  :  Bandelier  and  Ropke  recommend  a  series  of 
S7&K7'  ToW  ¥<H7  an(^  rlir  c-c->  an(l  this  may  be  taken  as  erring,  if  at  all, 
on  the  side  of  caution. 

The  reaction  consists  of  two  parts,  the  general,  and  the  focal :  there 
may  be  a  third,  the  needle-track  reaction. 

The  general  reaction  consists  in  a  rise  of  temperature,  usually  coming  on 
between  four  and  thirty  hours  after  the  injection.  The  height  of  the 
temperature  varies,  but  nothing  under  i°  F.  over  the  previous  maximum 
can  be  regarded  as  significant,  and  it  may  be  very  much  higher  than  this. 
The  usual  symptoms  of  fever  are  also  present. 

The  focal  reaction  is  most  important  in  that  it  serves  to  indicate 
the  region  affected  with  tubercle.  It  consists  of  an  inflammatory 
swelling  of  the  lesion,  which  may  be  observed  directly  (in  the  case  of 
lupus,  etc.)  or  indirectly,  by  its  pressure  effects  on  surrounding  structures. 

The  needle-track  reaction  is  not  always  seen.  It  consists  of  an  in- 
flammatory reaction  at  the  area  of  injection,  commencing  in  the  sub- 
cutaneous tissue  and  often  spreading  to  the  skin,  forming  a  red  spot 
with  sharply  outlined  edges.  It  is  less  important  than  the  general  and 
focal  reactions. 

TUBERCULIN  IN  TREATMENT. 

The  curative  value  of  tuberculin  is  undoubted.  There  are,  however, 
numerous  limitations  to  its  action  as  at  present  understood,  and  a  careful 
selection  of  cases  is  necessary  if  good  results  are  to  be  obtained.  Its 
use  is  not  indicated  if  the  diseases  is  directly  amenable  to  surgical 
measures,  e.g.  excision.  Thus  a  small  area  of  lupus  occurring  on  a  part 
of  the  body  hidden  by  clothing  should  be  excised.  Again,  it  is  difficult 
to  cure  lesions  in  which  there  is  a  large  mass  of  caseous  material  or  much 
fibrosis  :  good  results  are  occasionally  obtained  with  tuberculous  glands, 
but  this  is  the  exception,  and  as  a  rule  it  is  better  to  remove  them.  But 
in  cases  in  which  operation  is  not  practicable  or  advisable,  or  has  to  be 
deferred  from  any  cause,  tuberculin  should  certainly  have  a  trial. 

The  method  in  which  it  acts  is  not  precisely  known.  According  to 
Sir  Almroth  Wright  a  main  factor  in  its  action  is  the  increase  in  the 
amount  of  opsonin  in  the  serum  (already  alluded  to) ,  which  is  supposed 
to  increase  phagocytosis  and  thus  facilitate  cure.  There  are  theoretical 
objections  to  this  explanation,  and  it  is  found  as  a  matter  of  fact  that 
persons  with  a  low  opsonic  index  not  uncommonly  do  extremely  well. 
A  more  important  factor  is  probably  to  be  found  in  the  focal  reactions 
which  occur  after  each  injection.  These  flood  the  tissues  with  blood 
and  may  also  cause  a  profound  alteration  in  the  metabolism  of  the  cells. 
If  too  severe,  these  focal  reactions  may  go  on  to  necrosis  :  this  occurred 


TUBERCULIN  IN  TREATMENT  523 

with  the  rapidly  increasing  doses  used  in  the  early  days  of  the  treatment 
and  accounts  for  the  disrepute  into  which  it  fell.  One  of  the  main 
endeavours  of  the  surgeon  using  tuberculin  should  be  to  avoid  as  far 
as  possible  any  obvious  reaction,  either  local  or  general.  The  slight 
reactions  desired  are  inappreciable  except  in  rare  cases  such  as  tuber- 
culosis of  the  iris.  A  third  action  is  probably  the  production  of  anti- 
tuberculin  or  other  defensive  antibodies  by  which  the  patient  is  rendered 
more  or  less  immune  to  the  toxins  and  other  products  of  the  tubercle 
bacillus. 

The  forms  of  tuberculin  which  have  been  introduced  are  numerous 
in  the  extreme.  Koch's  old  tuberculin  consists  of  the  broth  in  which 
tubercle  bacilli  have  been  grown,  evaporated  to  one-tenth  of  its  bulk. 
It  is  the  most  potent  and  probably  the  most  valuable  form  of  tuberculin, 
but  its  use  requires  more  care  than  most  of  the  other  preparations. 
T.R.  contains  the  bodies  of  the  bacilli  themselves  in  a  fine  state  of  sub- 
division. It  is  less  potent  than  old  tuberculin,  and  should  be  used  in 
cases  in  which  there  is  fever.  It  is  easier  to  use  than  old  tuberculin, 
but  it  is  also  decidedly  less  efficacious,  and  where  it  is  used  in  the  com- 
mencement of  a  course  of  treatment  it  may  be  advisable  to  go  on  to 
the  other  form  subsequently.  Bacillary  emulsion  contains  the  bodies 
of  the  bacilli  themselves,  and  probably  also  some  old  tuberculin.  P.T.O. 
(Perlsucht-tuberculin-original)  is  tuberculin  prepared  from  bovine 
tubercle  bacilli  by  a  method  analogous  to  that  used  for  old  tuberculin, 
but  not  concentrated.  It  is  less  toxic  than  the  latter  substance,  and 
may  be  used  for  the  commencement  of  a  course  of  treatment. 

All  forms  of  tuberculin  have  to  be  diluted  before  use,  in  the  earlier 
stages  of  the  treatment  at  least.  Sterile  normal  saline  solution  should  be 
used  as  the  diluent,  and  J  per  cent,  of  carbolic  acid  or  lysol  should  be  added 
to  prevent  subsequent  bacterial  contaminations.  The  dilutions  should 
be  made  in  sterile  test-tubes,  and  a  hypodermic  syringe  may  be  used  to 
measure  the  various  fluids  required.  It  is  very  important  to  notice 
that  the  diluted  fluids  soon  lose  their  potency,  and  should  not  be  used 
more  than  four  days  at  the  utmost  after  being  prepared.  It  is  especially 
necessary  to  bear  this  in  mind  in  working  up  to  high  doses,  otherwise 
sharp  reactions  may  be  caused  when  a  fresh  and  potent  supply  of  tuber- 
culin is  used  after  some  that  has  become  inert. 

The  methods  of  giving  tuberculin  fall  under  three  main  types. 

(1)  The  Opsonic  Method.— Here  minute  doses  (sometimes  so  minute 
that  it  is  difficult  to  believe  that  they  have  any  action)  are  given,  the 
intervals  between  the  doses  and  the  amounts  in  each  being  regulated  by 
frequent  observations  of  the  opsonic  index,  an  attempt  being  made  to 
keep  this  at  a  high  level  for  as  long  a  period  as  possible.     The  results 
of  this  laborious  procedure  do  not  justify  the  amount  of  work  which 
it  entails,  and  the  method  is  generally  abandoned. 

(2)  The  Use  of  Small  Doses  at  Long  Intervals.— This  is  a  kind  of 


524  EXAMINATION  OF  THE  BLOOD 

modified  opsonic  method,  the  doses  and  intervals  being  about  those  which 
are  usually  found  desirable  when  the  method  is  controlled  by  the  examina- 
tion of  the  blood.  In  general  terms  the  doses  are  Y^IO  o  mgr-  °f  T.  R-  or  less 
and  the  intervals  seven  to  ten  days,  attention  being  paid  to  the  symptoms 
and  the  length  of  time  during  which  the  patient  seems  to  benefit  after 
each  injection.  Good  results  may  be  obtained  in  this  way,  and  no  harm 
can  result  :  it  is,  however,  being  rapidly  given  up  in  favour  of  the  intensive 
method,  in  which  the  amount  of  tuberculin  is  gradually  increased. 

(3)  The  intensive  method  should  be  preferred  in  all  cases  in  which 
the  patient  can  be  kept  under  constant  observation.  In  the  earlier 
stages  it  is  not  altogether  advisable  for  out-patients,  but  when  doses 
of  some  size  have  been  reached,  the  difficulties  are  less  and  the  intervals 
between  the  doses  longer,  and  a  patient  who  can  be  seen  twice  a  week 
may  be  treated  in  this  way.  It  is  necessary  that  an  accurate  record 
of  the  temperature  should  be  kept,  and  it  is  also  advisable  to  observe 
the  pulse  and  the  patient's  weight,  a  progressive  loss  of  the  latter  being 
an  indication  that  the  remedy  is  unsuitable  or  is  not  being  properly 
applied. 

The  doses  are  given  at  first  at  intervals  of  two  or  three  days,  and  it 
is  not  as  a  rule  desirable  to  go  much  longer  than  this  or  hypersensitiveness 
may  ensue.  In  the  later  stages  when  large  doses  are  reached,  the  interval 
increases,  and  the  maximum  amounts  may  be  given  at  weekly  intervals, 
or  even  more. 

The  commencing  doses  of  the  various  preparations  will  depend  to 
some  extent  on  the  general  health  of  the  patient  and  on  the  presence 
or  absence  of  fever,  but  in  general  terms  may  be  stated  as  follows  :— 
for  old  tuberculin,  TIF^¥  c.c.  or  less  ;  for  T.R.,  y-^  mgr.1  ;  for  bacillary 
emulsion,  TT^  mgr.  ;  for  P.T.O.,  y^o  c-c- 

Each  dose  is  larger  than  that  which  preceded  it,  the  idea  being  to 
increase  the  amount  given  as  quickly  as  possible  consistently  with  the 
avoidance  of  reactions.  In  general  terms  each  dose  may  stand  to  its 
predecessor  in  the  proportion  of  3:2,  i.e.  each  may  be  half  as  much  more 
as  the  previous  one,  but  this  is  only  a  rough  rule,  and  each  case  has  to 
be  considered  on  its  merits.  Bandelier  and  Ropke  give  as  an  example 
the  foUo  wing  series:  y^i^c.c.  of  old  tuberculin,  yo^oo  c-c.,  rWooo  c-c-> 


To1tFo~  C-C-,  retro  c-c->  ToiroTy  c-c->  i"otro¥»  TWO  c-c<>  T<JF<J  c-c-» 


T  07)0  C-C.,     T(jW  C-C-'     TW7  C-C-'     ToW  C-C.,    T0(7  C-C-,      iVo  C'C>'     T~o"0C-C- 
fto  C-C-,  -dfo  C-C-'  T£O  C-C-,  TO  C.C.,   V<J  C-C-,  T2o  C.C.,  fV  C.C.,  y^  C.C.,  y^C.C., 

1  In  the  preparation  of  T.  R.  10  mgrs.  of  tubercle  bacilli  are  used  for  i  c.c.  of 
the  ultimate  product,  and  the  amounts  quoted  are  calculated  as  if  this  were  all 
present  in  the  material  as  sold.  As  a  matter  of  fact  i  c.c.  only  contains  2  mgrs. 
of  dried  substance,  and  unnecessary  confusion  has  resulted  from  some  writers, 
who  calculate  their  doses  in  this  way,  stating  their  doses  as  one-fifth  of  those 
given  on  the  old  system  for  identical  amounts.  Bacillary  emulsion  contains  5  mgrs. 
in  i  c.c. 


TUBERCULIN  IN  TREATMENT          525 

i  c.c.,  which  is  the  usual  maximum  dose  in  cases  that  do  well  under  the 
treatment. 

The  maximum  dose  of  T.R.  may  be  taken  as  20  mgrs.  (or  2  c.c.  of  the 
original  fluid :  this  costs  175. ,  which  renders  it  an  expensive  remedy).  The 
maximum  dose  of  bacillary  emulsion  is  said  to  be  10  mgrs.,  and  of  P.T.O. 
i  c.c.,  after  which  a  more  potent  preparation  is  used. 

But  no  hard  and  fast  line  as  to  the  sequence  of  the  doses  can  be  laid 
down,  and  in  each  case  a  careful  study  of  the  patient's  temperature 
and  other  symptoms  is  necessary.  If  there  is  any  noticeable  reaction 
it  is  advisable  not  to  increase  the  dose,  but  to  administer  the  same  after 
the  fever  has  subsided :  this  may  be  necessary  more  than  once,  and 
the  amount  must  not  be  increased  until  this  dose  causes  no  reaction.  A 
reaction  obtained  after  a  moderate  increase  is  in  general  an  indication 
that  the  patient  is  highly  susceptible  and  is  an  indication  to  increase 
the  doses  slowly.  Bandelier  and  Ropke's  list  is  mainly  applicable 
to  phthisis,  and  in  surgical  tubercle  in  which  the  lungs  are  unaffected 
the  increases  may  often  be  somewhat  more  rapid,  and  an  occasional 
reaction  need  not  cause  alarm. 

The  injections  should  be  made  into  the  subcutaneous  {issues  of  the 
arm,  back  or  flank,  and  the  degree  of  local  reaction,  if  any,  round  the 
site  of  injection  carefully  noticed.  Occasionally  this  is  somewhat  severe 
and  'may  be  an  obstacle  to  further  progress,  necessitating  very  slow 
advances  in  the  dosage.  If  much  redness  and  swelling  are  produced  hot 
fomentations  may  be  applied. 

Tuberculin  has  been  given  by  the  mouth  and  does  not  appear  to  be 
entirelyTdevoid  of  action  when  administered  thus.  But  the  amount 
absorbed  is  uncertain,  and  the  advantages  of  the  method  are  not 
apparent,  whilst  its  disadvantages  are  obvious  :  in  any  case,  no  attempt 
to  administer  large  doses  in  this  way  must  be  made. 


INDEX 


A.C.E.  mixture,  463 

administration  of,  464 

advantages  of,  464 

apparatus  and  administration  of,  464 

cases  suitable  for,  464 

followed  by  ether,  466 

mask  for,  465 

objections  to  use  of,  465 

phenomena  of,  466 

preparation  and  position  of  patient 

in  administration  of,  464 
properties  of,  464 
Abscess, 

acute  circumscribed,  25,  27 
after-treatment  of,  30 
burrowing  of  an,  26 
diverticula  in  an,  26 
drainage  of,  28 

counter-opening  for,  29 
tube,  how  secured  in,  29 
dressing  after  incision  of,  30 
general  treatment  of,  31 
local  treatment  of,  27 
mode  of  extension,  26 
opening  of,  27 

Hilton's  method,  28 
symptoms  of,  27 
washing  out,  29 
chronic,  16,  230,  233 

attention  to  general  health  in, 

236 

excision  of,  233 
in  relation  to  tuberculosis,  16, 

23°,  233 

incision  and  scraping  of,  235 
partial  removal  of  wall  of,  234 
treatment  of,  233 
subacute,  26 

Absorption  of  complement,  509 
Accidental  incised  wounds,  163 
Acquired  club-foot, 
causes,  313 

treatment,  general  points  in,  319 
Actual  cautery 

in  treatment  of  naevus,  261 
chronic  inflammation,  20 
Acute  abscess,  circumscribed,  27 
after-treatment  of,  30 
burrowing  of  an,  26 
diverticula  in  an,  26 
drainage  of,  28 

counter-opening  for,  29 
tube,  how  secured  in,  29 


Acute  abscess,  circumscribed 

dressings  after  incision  of,  30 

gauze  wicks  in,  29 

general  treatment  of,  31 

local  treatment  of,  27 

mode  of  extension  of,  26 

opening  of,  27 

packing  with  gauze,  29 

symptoms  of,  27 

washing  out  of,  29 
bedsore,  76 
cellulitis,  31 
erysipelas,  196 
fevers,  gangrene  after,  80 
flat-foot,  301 
inflammation,  chap.  i.  1-15 

Bier's  treatment  of,  13 

blood-letting  in, 
general,  4 
local,  5 

cause,  removal  of,  3 

cold  in,  8 

dangers  of,  8 

cupping  dry,  7 

.  .   .      .  wet>  7 
drinks  in,  15 

drugs  in,  15 

evaporating  lotions  in,  9 

fomentations  in,  12 

food  in,  15 

free  incisions  in,  8 

general  symptoms,  3 

heat  in, ii 

ice-bag  in,  9 

lead  and  opium  lotion  in,  9 

lead  lotion  in,  9 

leeches,  5 

bleeding  from  bites  of,  6 
Leiter's  tubes  in,  10 

precautions  in  using,  10 
local  changes  in,  i 

treatment  of,  4 
pathology  of,  i 
position  in,  4 
poultices  in,  n 

advantages      and      disad- 
vantages of,  ii 
prognosis  of,  15 
purgatives  in,  14 
removal  of  cause,  3 
results  at  an  early  period,  i, 

a  later  period,  2 
scarification  in,  8 


527 


528  INDEX 

Acute  inflammation,  Anaesthesia,  general, 

spongiopilin  in,  13  auscultation  before,  445 

symptoms,  2  choice  of  anaesthetic,  446 

treatment  of,  4,  14  combined    nitrous    oxide     and 
'turpentine  stupes  in,  13  ether,  457 

pyaemia,  192  '  delayed  chloroform  poisoning,' 

septicaemia,  173.  189  479 

vaccines  in,  189  diet  after,  479 
suppuration,  chap.  ii.  25-38  before,  444 

causes  of,  25  difficulties  and  dangers,  471-475 

in  the  tissues,  25,  26  glottis,  spasm  of,  471 

tetanus,  199  in  special  cases,  467 

traumatic  gangrene,  83  position  of  patient,  446 

Adenomata,  240  preliminary  hypodermic  injec- 
Adherent  cicatrix,  207  tions",  444 

Adrenalin  in  treatment  of  shock,  121  preparation  of  patient  for,  443 

Adrenalin  chloride  respiratory  troubles  during,  472 

as  a  styptic,  in  sickness  after,  478 

with  local  anaesthetics,  484,  485  signs  of  danger  during,  471 
Aerial    infection,    avoidance   of,    during  treatment  of,  472 

operations,  104  status  lymphaticus,  471 

Age  as  factor  in  production  of  tuber-  surgical  shock  in,  479 

culosis,  229  syncope  during,  471 
Air,  entry  of,  into  veins,  122                                    local,  480-486 

Alcoholics,  administration  of  anaesthetics  advantages  of,  480 

in,  470  alypin  in,  484 

Alexin,  509  anaestile  in,  482 

Alibert's  cheloid,  204  Barker's    solution    of    eucaine, 
Allis's  ether  inhaler,  455  485 

Alveolar  sarcoma,  244  cases  suitable  for,  481 

Amboceptor,  509  cocaine  in,  483 

Ambulatory  treatment  of  ulcers,  59  conduction  anaesthesia,  485 

Ammonia  in  septic  intoxication,  187  drugs  for,  482,  483,  484 

Amputation  in,  ether  spray  for,  482 

acute  septicaemia,  190  ethyl  chloride  for,  482 

traumatic  gangrene,  83,  84  eucaine  for,  485 

burns,  180  freezing  in,  482 

chronic  septicaemia,  191  infiltration  in,  485 

diabetic  gangrene,  81  methods  of,  481 

frost-bite,  184  objections  to,  481 

gangrene  due  to  Schleich's  method  of,  485 
crushing,  69                                                 spinal,  486 

ergot,  82  after-effects,  489 

obstruction   of    blood    vessels,  apparatus   and  procedure,  487 

75  Barker's  solution  for,  487 

lacerated  wounds,  171  cases  suitable,  487 

senile  gangrene,  74  difficulties,  488 
talipes  equino-varus,  358                                venous,  486 

equinus,  333  Anaesthetic,    choice    of,    factors    deter- 

tetanus,  202  mining,  446 
Anaesthesia,  conduction,  485                                  mixtures, 

false,  461  A.C.E.  463 

general,  443-480  Billroth's,  463 

administration  of  chloroform  and   ether,  464 

A.C.E.  mixture,  464  Vienna,  463 
chloroform,  458                         Anaesthetics, 
ether,  452                                            administration  of,  in 

nitrous  oxide,  448  alcoholics,  448,  470 

nitrous  oxide  and  ether,  457  intra-cranial  operations,  467 

nitrous  oxide  and  oxygen,  nose  and  mouth  operations,  467 

451  severe  operations,  470 

after-treatment  of,  477  special  cases,  467-470 

asphyxia  during,  472  thyroidectomy,  469 


INDEX 


529 


Anaesthetics, 

difficulties     and     dangers     in     ad- 
ministering, 471 
general,  443 

A.C.E.  mixture,  4<>3 
chloroform,  458 
ether,  453 
ethyl  chloride,  .}'•<> 
nitrous  oxide,  448 
nitrous  oxide  and  ether,  457 
influence  on  shock,  118 
local , 

alypin,  484 
cocaine,  483 
eucaine,  484 
novocaine.  484 
stovaine,  484 
tropocaine,  484 
Anaestile,  482 
Anatomical  warts,  172 
Anchylosis,    danger    of,    in    gonorrhoeal 

flat  foot,  301 
Angioma,  capillary,  255 

cavernous,  255 
Angiomata, 

treatment  by, 

carbolic  acid,  260 
caustics,  259 
cauterisation,  261 
electrolysis,  256 
electrolysis  and  compression, 259 
ethylate  of  sodium,  260 
excision,  255 
freezing,  262 
radium,  264 
Ankles,  weak,  310 
Anterior  metatarsalgia,  287 
Antibody,  509 
Antigen,  509 
Antiphlogistine,  13 
Antipyrin  in  pyaemia,  195 
Anti-streptococcic  serum  in 
acute  septicaemia,  189 
chronic  pyaemia,  196 
diffuse  cellulitis,  38 
erysipelas,  199 
general  septic  infection,  173 
poisoned  wounds,  173 
wounds  of  mucous  membranes,  163 
Anti-streptococcic  serum,  polyvalent,  173 
Anti-tetanic  serum,  201 
Aperients  after  operations,  126 

before  operations,   88 
Arthrodesis,  341 
Artificial  instep,  303 

respiration  in 
anaesthesia,  476 
entry  of  air  into  veins,  123 
poisoning  by  carbonic  oxide, 

177 

Aseptic  treatment  of  wounds,  136 
Asphyxial  symptoms  in  anaesthesia,  .\~ i 
Aspirin  after  operations,  125 

I. 


Asthenic  inflammatory  fever,  3 
Astragalo-scaphoid  capsule,  345,  351 

joint,  excision  of,  in  flat  foot,  309 
Astragalus,  changes  in  congenital  talipes, 

31.3 
excision  of, 

in  cicatricial  club-foot,  321 
talipes  equino-varus,  358.  361 

equinus,  332 

excision  of  head  of,  in  flat-foot,  309 
obliquity    of    neck    of,    in    talipes 

equino-varus,  345 
partial     resection     of,     for    talipes 

equinus,  333 
Atrophic  scirrhus,  241 
Atropine,  injection  of,  before  anaesthesia, 

445 
Ausculation  preliminary  to  anaesthesia, 

445 

Auto-infusion,  120 
Axilla,  infusion  of  saline  solution  into,  120 


BACILLUS  aerogenes  capsulatus,  83 
Bacillus  coli  vaccine,  dose  of,  518 
Bacteriological  examination  of  blood,  502 
Bandage,  elastic,  48 
Esmarch's,  106 
Martin's,  48,  59 
Barker's  flushing  spoon,  156 

solution  for  local  anaesthesia,  485 

spinal   anaesthesia,  4X7 
Bedsore,  acute,  76 
prophylaxis,  70 
treatment,  70 
Benign  tumours,  239,  250 
Bier's  treatment,  13 
Bifid  finger,  269 

Bilharzia  disease,  blood-count  in,  508 
Billroth's  mixture,  463 
Blanket  or  button-hole  stitch,  142 
Bleeding  from  leech-bites,  6 
Blisters,  counter-irritation  by,  19 
in  treatment  of  ulcers,  49 
treatment  of,  in  burns,  177 
Blood,  bacteriological  examination  of,  502 
freezing  point  of,  504,  505 
symptoms  of  serious  loss  of,  112 
Blood-clot,  healing  by,  129 
Blood-count  in  bilharzia,  508 
in  chlorosis,  508 
hydatids,  508 
leucocythacmia,  507 
lymphadenoma,  507 
lymphatic  leucocyttuemia,  507 
malaria,  508 
malignant  disease,  507 
pernicious  anaemia,  507 
secondary  anaemia,  508 
septicaemia,  506 
suppuration,  506 
syphilis,  506 
trichinosis,  508 

MM 


530 


INDEX 


Blood-count  in  tuberculosis,  506 
typhoid,  508 
viscus,  perforation  of,  508 
Blood  in  surgical  conditions,  examination 

of,  490-518 

bacteriological  examination  of,  502 
'  colour  index,'  502 
differential  leucocyte  count,  496 
freezing  point  of,  504,  505 
haemoglobin,  estimation  of,  500 
leucocytes,  differential  count,  496 
enumeration  of,  490 
iodine  reaction,  499 
leucocytosis,  494 

in  various  affections,  506 
leucopenia,  495 
'  opsonic  index,1  503 
red  corpuscles,  examination  of,  499 
Wassermann  reaction,  508 
'  Bloodless  '  operations,  107 
Blood-letting,  general,  4 

local,  5 

Blood-vessels,  waxy  degeneration  of,  190 
Boiling  as  means  of  disinfection,  92 
Bone-changes, 

in  flat  foot,  299-300 

talipes  equino-varus,  345 
equinus,  322 
valgus,  342 
Boots  in  flat  foot,  306 

after  excision  of  astragalus,  333 

tenotomy    of    tendo    Achillis, 

328 

for  hallux  valgus,  281 
metatarsalgia,  288 
in  talipes  calcaneus,  336 

equino-varus,  355-361 
valgus,  343 

Bordet-Genjou  phenomenon,  509-510 
Boric  dressing,  wet,  in  ulcers,  51 

lint  and  protective  in  ulcers,  51 
ointment  in  ulcers,  51 
Bow  legs  (see  Tibia  and  fibula,  curved), 
treatment,  363 
general,  363 
local,  365 

cuneiform     osteotomy     of 

tibia,  368 
electricity  in,  365 
in  advanced  stages,  366 

early  stages,  365 
manipulations  in,  366 
operations  for,  367 
osteotomy,  linear,  368 
splints  in,  366 

Gooch's,  369 

Brandy  in  septic  intoxication,  187 
Breast,  cysts  of,  265 
Bunion,  279 
causes,  279 
splint  for,  282 
spring,  283 
suppurating,  286 


Bunion,  treatment,  operative,  283 

excision    of    head    of     metatarsal, 

285 
removal  of  enlarged  portion  of  first 

metatarsal,  283 
results  of  operation,  285 
silicate  bandage  in,  285 
splint  after  removal  of  bone,  284 
when  suppuration  has  occurred,  286 
Burns  and  scalds,  174-180 

asepsis  in  treatment,  importance  of, 

178 

carron  oil  in,  179 
causes  of  death  after,  176 
constitutional  phenomena  of,  175 
contraction  of  fingers  after,  296 
degrees  of,  174,  175 
disinfection  of,  178 
duodenal  ulcer  in,  176 
picric  acid  in  treatment  of,  179 
skin-grafting  in,  179 
treatment  of,  general,  176 
in  extremities,  179 
local,  177 
picric  acid,  179 
water  bath  in,  179 
Burns  due  to  radium,  174 
X-rays,  174 

'  Burrowing  '  of  acute  abscess,  26 
Button  cautery,  21 

sutures,  140 
Button-hole  stitch,  142 


CALCANEUS,  talipes,  335 
Calcification  in  tuberculosis,  230 
Calcium  lactate  in  haemorrhage,  in 
Callous  ulcer,  characters  of,  44 

special  points,  in  treatment  of,  63 
Calmette's  test,  521 
Camphor,  use  of,  in  treatment  of  shock, 

121 

Cancer,  encephaloid,  241 

melanotic,  242 
Cancrum  oris,  85 
Capillary  angioma,  255 
Carbolic  acid,  as  an  anaesthetic,  483 
dangers  of,  100 
in  erysipelas,  199 
naevi,  260 
septic  sinuses,  166 
ulcers,  50 
wounds,  165 

precautions  in  use  of,  100 
undiluted  in  diffuse  cellulitis,  32 
oil  in  treatment  of  ulcers,  50 
Carbonic    acid    in    treatment    of    naevi, 

261 

oxide  poisoning,  176 
treatment  for,  177 
Carcinomata,  241 

atrophic  scirrhus,  241 


INDEX  53I 

Carcinoraata,  colloid  degeneration  in ,242     Chloride   of  zinc  in  wounds  of  mucous 
encephaloid,  241  membranes,  162 

epithelioma,  241  Chloroform,  administration  of,  458 

mode  of  spread  of,  241  after-effects  of,  462 

removal  of  lymphatic  tract  in,  242  apparatus     for    administration    of 

treatment  of,  242  459 

Carron  oil  in  treatment  of  burns,  179  cases  suitable  for,  458 

Caseation  in    relation    to    tuberculosis,  delayed  chloroform  poisoning.  479 

23°  dosimetric  methods,  463 

Catgut,  Lister's  sulpho-chromic,  93  in  tetanus,  203 

Caustics  in  treatment  of  naevi,  259  Junker's  inhaler  for,  459 

Cautery,   actual,    in   chronic    inflamma-  with  tube,  467 

tion,  20  phenomena  during  anaesthesia,  460 

button,  21  preparation  and  position  of  patient 

Corrigan's,  21  in  administration  of,  459 

in  haemorrhage,  108  properties  of,  458 

naevi,  261  Schimmelbusch's  inhaler,  459 

phagedena,  84  Vernon-Harcourt  inhaler,  462-463 
phagedenic  ulcer,  63                            Chlorosis,  blood-count  in,  508 
tuberculous  joints,  233                         Chondrifying  sarcoma,  253 
Paquelin's,  21                                             Chondromata,  252 

Cavernous  angioma,  255  changes  in,  253 

lymphangiomata,  264  treatment  of,  253 
Cellulitis,  diffuse,  31-38                                  Chondro-sarcoma,  244 
after-treatment  of,  32                               Chronic 

anti-streptococcic  serum  in,  38  abscess,  16,  230,  233 

general  treatment  of,  37  attention  to  general  health  in, 

incisions  in,  31  236 

irrigation  in,  32  excision  of.  233 

local  treatment  of,  31  in     relation     to     tuberculosis, 

massage  in,  37  230 

moist  dressings  in,  35  incision  and  scraping  of,  235 

movements  in,  37  partial  removal  of  wall  of,  234 

position  in,  36  treatment  of,  233 

rest  in,  36  infective  ulcers,  39 

symptoms  of,  31  inflammation,  16 

undiluted  carbolic  acid  in,  32  as  a  factor  producing  tubercu- 

vaccine  treatment  of,  38  losis,  229 

water  bath  in,  34  blisters  in,  19 

Celluloid  shields  for  ulcers,  52  causes  of,  16 

Chancre,  extra-genital,  209  removal  of,  16 

hard  or  Hunterian,  209  changes  in  the  tissues,  16 

of  inflamed  inguinal  glands,  counter-irritation  in,  18 

phagedenic,  217  by  actual  cautery,  20 

Charcoal  poultices,  n  blisters,  20 

Charcot's   disease  as    a  cause   of  genu  precautions  in  ap- 

valgum,  371  plying,  20 

Cheloid,  204  croton  oil,  20 

causes  of,  204  iodine,  19 

cod  liver  oil  in,  205  mustard,  19 

excision  of,  205  free  incision  in,  21 

fibrolysis  in  treatment  of,  205  general  treatment  of,  24 

scarification  of  scar  in,  205  massage  in,  23 

treatment  of,  205  pathology  of,  16 

X-ray  treatment  of,  205  position  in,  18 

Chilblains,  180  pressure  in,  22 

treatment  of,  182  removal  of  cause  of,  18 

flexile  collodion  in,  182  rest  in,  18 

glycerine  and  belladonna  in,  183  Scott's  dressing  in,  23 

Chinese  twist,  143  strapping  in,  23 

Chloral,  use  of,  in  tetanus,  202  symptoms  of,  17 

Chloride  of  ethyl,  466,  468  treatment  of,  18-24 

zinc  in  ulcers,  50  non-infective  ulcers,  39 

MM2 


532 


INDEX 


Chronic  pyaemia,  195 

treatment  of,  195 

anti-streptococcic  serum  in, 

196 
septicaemia,   190 

amputation  in,  191 
general  treatment  of,  192 
local    operations   in   treatment 

of,  191 
where  focus  of  disease  can 

be  removed,  191 
where     focus     of     disease 
cannot  be  removed,  191 
tetanus,  200 

Cicatrices,  affections  of,  chap  x.  204-208 
as  causes  of  club-foot,  314 
epithelioma  affecting,  207 
Cicatricial  contraction  as  cause  of  talipes 

equino-varus,  345 
form   of  club-foot,   amputation   in, 

321 

Cicatrix,  adherent,  207 
contracting,  206 
painful,  206 
Circumscribed  acute  abscess,  27 

encapsuled  tumours,  238 
Climatic   condition   as   a   factor   in   the 

production  of  tuberculosis,  230 
Clothing  for  rickety  children,  365 
Clover's  inhaler  for  administration  of 

ether,  453 

Club-foot  (see  Talipes),  chap.  xvi.  312-362 
causes,  312 
definition,  312 
individual  forms,  312 
pathological  changes  in,  312 
treatment,  general  indications,  314 
varieties, 

acquired  cases,  313 

treatment    of,   general    in- 
dications for,  319 
cicatricial,  319 
paralytic,  319 
spastic,  319 
congenital,  312 

treatment   of,    general   in- 
dications for,  315 
individual  forms, 

talipes  calcaneus,  335 
cavus,  334 
equino-valgus,  344 
equino-varus,  344 
equinus,  321 
valgus,  342 
varus,  344 
Club-hand,  361 

Cocaine  as  a  local  anaesthetic,  483 
dangers  of,  484 
hypodermically,  483 
instillations  of,  483 
painting  with,  484 
spray,  483 
Codeine  in  diabetic  gangrene,  81 


Cod   liver  oil  in  treatment   .of    cheloid, 

205 

in  tuberculosis,  232 

Cold,  application  of,  in  acute  inflamma- 
tion, 8 

clinical  effects  of,  181 
dangers   of,  in  acute  inflammation, 

8 

for  controlling  haemorrhage,  no 
friction  in  treatment  of,  182 
in  Raynaud's  disease,  77 
limits  of  use  of,  in  acute  inflamma- 
tion, 9 

local  effects  of,  180 
treatment  of  effects  of,  182 
tuberculosis  as  an  effect  of  exposure 

to.  228 

ulcers  as  effect  of,  181 
Coley's  fluid,  249 
Collodion    in    treatment    of    chilblains, 

182 

salicylic,  239 

Colloid  degeneration  in  carcinoma,  242 
'  Colour  index/  502 
Complement,  509 
Complex  tumours,  265 

connective  tissue  tumours,  254 
dermoid  cysts,  265 
Compress,  graduated,  109 
Conduction  anaesthesia,  485 
Condylomata,  treatment  of,  224 
Congenital  absence  of  radius,  361 
club-foot,  312 
causes,  312 

treatment,    general    considera- 
tions in,  315 

correction   of   position    in, 

316 

duration  of,  315 
exercises,  318 
galvanic  current,  318 
manipulations,  316 
massage,  316,  318 
operations,  319 
splints   in    various    stages, 

317,  318 

tenotomy  for,  318 
contraction  of  fingers,  289 
dislocation  of  head  of  radius,  402 
of  hip,  393 

knee  joint,  402 
patella,  402 
shoulder,  402 
elevation  of  scapula,  297 
Connective  tissue  tumours 
benign,  250 

chondromata,  252 
exostoses,  253 
fibromata,  251 
lipomata,  251 
moles,  251 
myxomata,  250 
osteomata,  253 


INDEX 


533 


Connective  tissue  tumours, 
complex,  254 

angiomata,  255 
cysts,  265 
gliomata,  255 
lymphadenoma,  264 
lymphangiomata,  264 
lymphosarcomata,  264 
myomata,  254 
naevi,  255 
neuromata,  254 
sacro-coccygeal  tumours,  265 
malignant,  243 

sarcomata,  243 

varieties  of,  244 
Continuous  sutures,  142 
Contracting  cicatrix,  206 
Contraction,  Dupuytren's,  290 
Contractions  of  fasciae, 
of  fingers,  289,  296 

after  burns,  296 
Contused  wounds,  169 
Contusions,   causes    and    treatment   of, 

169 
Corns,  240 

plasters  for,  240 
Corrigan's  cautery,  21 
Counter-irritation  in  chronic  inflamma- 
tion, 1 8,  233 
by  croton  oil,  20 
Counter-opening  for  drainage,  29 
Coxa  valga,  392 
vara,  386 

pathological  changes  in,  387 
treatment  of,  388 
Crile's  clamps,  107,  108 

pneumatic  suit,  120 
Croton  oil  for  counter-irritation,  20 
Cuneiform     osteotomy,    of     the     tibia, 

368 
tarsectomy,  358 

after-treatment    of   wound    in, 

360 

splint  after,  361 
suture  of  incisions  in,  360 
Thomas's  wrench  in,  359 
Cupping,  dry  and  wet,  7 
Curvature  of  spine,  angular,  403 
kyphosis,  403 
lateral,  405 
scoliosis,  405 
Curvatures  of  neck  of  femur,  chap.  xix. 

386-392 
Curved     tibia    and    fibula,    chap.    xvii. 

363-370 

manipulations  for,  366 

massage  for,  365 

osteotomy  for,  367 

splints  for,  366 

Cuti-reaction  in  tuberculosis,  520 
Cyanide  gauze  (Lister's),  151 
Cystic  lymphangiomata,  264 
Cysts,  dermoid  and  sebaceous,  265 


DANGERS    in    administration    of    anaes- 
thetics 

of  chloroform,  462 
ether,  456 
mixtures,  466 
nitrous  oxide,  450 
operations,  99 
Deep  structures,   approximation  of,  in 

wounds,  133 
sutures,  133,  136 
Deformities, 

bow-legs,  chap.  xvii.  363-370 
bunion,  279 

club-foot,  chap.  xvi.  312-361 
congenital   dislocation   of   the   hip, 

chap.  xx.  393-402 
pathology  of,  393 
treatment,  394-402 
in  infancy,  395 
Lorenz's  method,  395 
operative,  400 

contractions  of  the  fingers,  289 
coxa  valga,  392 
vara,  386 

curvature  of  the  neck  of  the  femur,  386 
spine,  angular,  403 

lateral,  405 
curved  tibia  and  fibula,  chap.  xvii. 

363-370 

dislocation,  congenital,  of  hip,  393 
head  of  radius,  402 
knee  joint,  402 
patella,  402 
shoulder,  402 

Dupuytren's  contraction,  290 
femur,  curvature  of  the  neck    of, 

chap.  xix.  386-392 
fingers,  267-289 
flat-foot,  chap.  xv.  299-310 
foot,  299 
genu  recurvatum,  384 

valgum,  chap,  xviii.  371-383 
varum,  383 
hallux  flexus,  286 
rigidus,  286 
valgus,  279 
hammer  toe,  275 
hip,  congenital  dislocation  of,  chap. 

xx.  393-4°2 

metatarsalgia,  Morton's  disease,  287 

superfluous  digits,  267 

supernumerary  digits,  267 

talipes  (see  Club-foot) 

tibia  and  fibula,  curved,  363 

toes,  275 
Degrees  of  burn,  174 

treatment  of,  177,  178 
'  Delayed  chloroform  poisoning,'  479 
Depletion,  local,  in  inflamed  ulcer,  61 
Dermoid  cysts,  265 
Desks,  proper  proportions  for  children, 

413 
Diabetes,  diet  in,  80 


534 


INDEX 


Diabetic 

gangrene,  79 

amputation  in,  81 
treatment  of,  80 
ulcer,  characters  of,  45,  65 

special  points  in  treatment  of,  65 
Didot's   operation  for   webbed    fingers, 

273 

Diet  after  anaesthesia,  479 
in  pyaemia,  195 

secondary  syphilis,  218 
tetanus,  203 
tuberculosis,  236 
Difficulties  and   dangers  in  anaesthesia, 

47i 
Diffuse  cellulitis,  31 

active  movements  in,  37 
after-treatment  of,  32 
anti-streptococcic  serum  in,  38 
general  treatment  of,  37 
incisions  in,  31 
irrigation  in,  32 
local  treatment  of,  31 
massage  in,  37 
moist  dressings  in,  35 
passive  movements  in,  37 
position  in,  36 
rest  in,  36 
symptoms  of,  31 
undiluted  carbolic  acid  in,  32 
vaccine  treatment  of,  38 
water  bath  in,  32,  34 
lipoma,  251,  252 
Digitaline  in  septic  intoxication,  187 

shock,  121 

'  Digitated  '  socks,  281 
Digits,  superfluous,  267 

webbed,  270 

Diphtheritic  and  phagedenic  ulcer, 
characters  of,  44 
treatment  of,  63 
Direct  gangrene,  69-72 
Disease,  lardaceous,  190 
Disinfection  of  burns,  178 

contused  wounds,  170 
gangrene,  68,  69,  73 
hands  of  operator,  101 
instruments,  92 
lacerated  wounds,  171 
ligatures,  93,  94,  95 
sinuses,  166 
skin,  99 

sponges,  95,  104 
ulcers,  49 
Diverticula  in  acute  abscesses,  26 

mode  of  opening,  28 
Dowd's  machine,  420 

exercises  with,  430 
Drainage  of  acute  abscess,  28,  29 
of  wounds,  147 

indications  for,  149 

in  septic  intoxication,  187 

traumatic  fever,  188 


Drainage  tube,  mode  of  introduction  into 

abscess,  29 

securing  in  position,  29 
Dressings  in  acute  abscess,  30 
burns,  178 
incised  wounds,  150 
how  to  change,  152 
when  to  change,  151 
moist,  in  diffuse  cellulitis,  35 
preparation  of,  96 
treatment  of  oozing  through,  116 
Drugs  in  acute  inflammation,  15 

septicaemia,  189 
burns  and  scalds,  177 
chilblains,  183 
diabetic  gangrene,  So 
erysipelas,  197,  198 
pyaemia,  94 
Raynaud's  disease,  79 
senile  gangrene,  74 
septic  intoxication,  187 
traumatic  fever,  189 
tuberculosis,  232 
Dry  cupping,  7 

gangrene,  67 

Duodenal  ulcer  in  burns,  176 
Dupuytren's  contraction, 
pathology,  290 
treatment,  290-296 

after-treatment,  292 
choice  of  operation  in,  291 
excision  of    contracted    fascia, 

293  >  295 

open  operations  in,  293 
subcutaneous  division  of  fascia, 

291 
tenotomy,  results  of,  293 


ECZEMA,  varicose,  44 
Effleurage  in  massage,  23 
Ehrlich's  '  606,'  212 
Elastic  bandage,  Esmarch's,  106 

Martin's,  48 
Electric  bath  in  paralytic  ulcer,  64 

Raynaud's  disease,  77 
Electricity  in  anaesthesia,  477 

paralytic  ulcer,  64 

severe  cold,  183 

syncope,  during  operations, 

124 

Electrolysis  in  treatment  of 
angiomata,  256 
lymphangiomata,  264 
naevi,  256 

ulcers  from  cold,  183 
Embolic  gangrene,  75 
Empyema  as  a  cause  of  scoliosis,  407 
Encapsulation  in  tuberculosis,  230 
Encephaloid  cancer,  241 
Endotheliomata,  243 
Enema,  nutrient,  in  shock,  121 
preparatory  to  anaesthesia,  444 


INDEX 


535 


Entry  of  air  into  veins,  122 
Eosinophiles,  497,  498 

in  parasitic  diseases,  508 
Epithelial  tumours,  238 
benign  varieties,  239 
malignant  varieties,  241 
Epitheliomata, 

affecting  cicatrices,  207 
cylindrical,  241 
squamous,  241 

Equino-varus,  talipes,  344-361 
Equinus,  talipes,  321-334 
Ergot,  gangrene  from,  82 
Erysipelas,  196 

gangrenous,  197 
general  treatment  of,  197 
local  treatment  of,  198 
pathology  of,  197 
phlegmonous,  197 
symptoms  of,  196 
treatment  of,  197 

anti-streptococcic  serum  in, '199 
carbolic  acid  in,  199 
ichthyol  in,  198 
iodine  in,  198 
Kraske's  method,  198 
lead  lotion  in,  199 
nitrate  of  silver  in,  198 
phlegmonous  cases,  197 
prophylactic,  197 
varieties  of,  197 
Esmarch's  bandage  in  haemorrhage,  106 

tourniquet,  106 
Estlander's  operation,  192 
Ether,  administration  of,  452 

administration  and  apparatus,  453 

open  method  of,  454 
after-effects  of,  456 
Allis's  inhaler  for,  455 
cases  suitable  for,  452 
Clover's  inhaler  for,  453 
combined  with  nitrous  oxide,  457 
dangers  of  administration  of,  456 
open  method  of  administering,  454 
preceded   by  A.C.E.   mixture,  447, 

448 
preparation  and  position  of  patient, 

453 

properties  of,  452 
rash,  455,  466 
special  points  in  administration  of, 

455 

spray  for  local  anaesthesia,  482 
stages  of  anaesthetisation  by,  454 
Ether,  in  septic  intoxication  of  wounds, 
187 

in  shock,  120 
Ethyl  chloride,  administration  of,  466 

as  a  local  anaesthetic,  482 
Ethylate    of    sodium    in    treatment    of 

naevi,  260 

Eucaine  as  a  local  anaesthetic,  484 
Evaporating  lotions,  9 


Excision  of  cheloid,  205 

chronic  abscess,  233 
lymphatic  tract  in  carcinoma, 

242 

naevi,  255 

astragalus  in  equinus,  332 
flat  foot,  310 
head    of   astragalus   in    flat 

foot,  309 
head  of  first  metatarsal  for 

hallux  valgus,  285 
head  of  phalanx  in  hammer 

toe,  278 

lymphangiomata,  264 
naevi,  255 
palmar  fascia  in  Dupuytren's 

contraction,  293 
primary  chancre,  217 
wedge  from  neck  of  femur  in 

coxa  vara,  391 
wedge   from   tarsus   in   flat 

foot,  310 
wedge  from  tarsus  in  talipes, 

358  . 

Exercises  for  strengthening  spinal  liga- 
ments, 438 
in  flat  foot,  302,  307 

scoliosis,    414,  416,    417,    418, 

421,  423 
talipes,  318,  328 
muscular,  423-439 
Exostosis,  253 
ivory,  253 

of  skull,  254 
spongy,  253 

Exploratory    incision    for    diagnosis    of 
nature  of  tumours,  245 

FALSE  anaesthesia,  461 
Faradism  in  talipes  calcaneus,  335 
Feeding  after  operations,  125,  479 
before  operations,  88,  444 
in  rickets,  363 

Femur,  changes  in,  in  genu  valgum,  372 
curvatures    of   neck  of,  chap.  xix. 

386-392 
causes,  386 

pathological  changes,  387 
symptoms,  387 
treatment,  388 

division  of,  in  genu  varum,  384 
Femur  and  tibia,  osteotomy  of, 
in  genu  valgum,  381 
varum,  384 

Fever,  asthenic  inflammatory,  3 
hectic,  190 

sthenic  inflammatory,  3 
traumatic,  188 
Fibroblasts,  16 
Fibrolysin  in  cheloid,  205 

in  Dupuytren's  contraction,  290 
Fibromata,  hard  and  soft,  251 
of  naso-pharynx,  251 


536 


INDEX 


Finger,  bifid,  treatment  of,  269 
Fingers,  contractions  of,  289 

after  burns,  296 
bifid,  269 
superfluous,  267 
webbed,  270 

Didot's  operation,  273 
ear-ring     perforation     method, 

271 

V-shaped  flap  method,  272 
treatment     where     bones     are 

united,  275 
varieties,  271 
Fingers  and  toes,  deformities   of,  chap. 

xiv.  267-298 

First  intention,  healing  by,  127 
causes  inimical  to,  128 

of  failure  to  secure,  154 
Flaps,  undermining,  140 
use  of,  158,  159 

granulating,  160 
Flat  foot,  chap.  xv.  299-310 
causes  of,  299 

changes  in  bones  in,  299,  300 
as     an     accompaniment     of     genu 

valgum,  279 

pain  in,  nature  and  seat  of,  300 
pathological  changes  in,  299,  300 
treatment  of,  300 

astragalus,  removal  of  head  of, 

309 

astragalo-scaphoid     joint,     ex- 
cision of,  309 
Barwell's  splint  in,  307 
boots  for,  306 
exercises  for,  302,  307 
elastic  traction  in,  307 
fixation  in  acute  forms,  301 
forcible  manipulations  in,  307, 

308 

Golding  Bird's  apparatus,  307 
Ogston's  operation,  309 
Stokes' s  operation,  310 
tarsectomy,  310 
Thomas's  wrench  in,  308 
Whitman's  spring,  303 
varieties  of, 

acute,  299,  300,  301 
acute  gonorrhoeal,  301 
chronic,  299,  306 
rheumatic,  301 
traumatic,  296 
Fleming's  modification  of  Wassermann's 

test,  511 
Fomentations    in    acute    inflammation, 

12 

Food  in  acute  inflammation,  15 
Forceps    for  arrest  of  haemorrhage,  no 
Crile's  clamp,  107 
Grieg  Smith's,  no 
Lawson  Tait's,  109 
Spencer  Wells's,   no 
tongue,  475 


Foreign  bodies  in  chronic  inflammation, 

i? 

Freezing  in  local  anaesthesia,  482 
Friction  in  treatment  of  frostbite,  182 

Raynaud's  disease,  78 
massage,  23 
Frostbite,  181 

amputation  in,  184 
disinfection  in,  183 
treatment,  183 
Fumigation,  mercurial,  in  syphilis,  222 


GAG,  mouth,  475 

Galvanism  for  talipes,  318,  335,  342 
Gangrene,  chap.  iv.  67-86 
acute  traumatic,  83 
after  acute  fevers,  81 
treatment  of,  82 
bedsore,  70,  76 
*  treatment,  70-71 

cancrum  oris,  85 
classification  of,  67 
clinical,  67 
ctiological,  67 
definition  of,  67 
diabetic,  79 

treatment,  general,  80 

local,  8 1 
direct,  69 
dry,  67,  72 
due  to  crushing,  69 

amputation  in,  69 
treatment  of,  69 
endarteritis,  82 

general  causes,  72,  79 
pressure,  70 

from  acute  inflammation,  72 
ergot,  82 
imperfect  innervation,  76 

acute  bedsore  in,  76 
obstruction  of  blood-vessels,  75 
embolus,  75,   82 
thrombus,  75,  82 
general  treatment  of,  68 
indirect,  72 
infective,   82 

local  treatment  of,  83,  84,  85 
moist,  67 
noma,  85 
phagedenic,  84 
Raynaud's  disease,  76 

treatment,  general,  79 

local,  77 
senile,  72 

treatment,   73 
symptoms  of,  67 
treatment,  general,  68 

local,  68 

Gangrenous  erysipelas,   197 
Genu  recurvatum,  causes  and  treatment 
of,  384 


INDEX 


537 


Genu  valgum,  causes,  371 
curve,  situation  of,  372 
definition  of,  371 
femur,  changes  in,  371,  372 
flat  foot  as  an  accompaniment  of,372 
spontaneous,  371 
tibia,  changes  in,  372 
treatment  of,  372 
general,  373 
local,  373 

malleoli,  distance  between 

as  regards,  373 
manipulations  in,  373 
massage  in,  373 
mechanical,    duration    of, 

375 
operations,  indications  for, 

376 

orthopaedic  apparatus,  375 
osteotomy,  376 

after-treatment,  381 
apparatus  after,  382 
Macewen's,  377 
from     outer     side     of 

femur,  380 
of  tibia,  381 
of  tibia  and  femur,  381 
splints  in,  374 
Gooc.h's,  381 
plaster  of  Paris,  381 
Thomas's  hip,  374 
walking  apparatus,  374,  375 
walking,  restriction  in,  373 
Genu  varum,  causes  and  treatment,  383 
operations  for,  383 
osteotomy  for,  383,  384 
splints  in,  383 
Gibert's  '  syrup,'  220 
Gliomata,  255 

Glottis,  spasm  of,  in  anaesthesia,  471 
Gloves,  use  of,  in  operations,  101 
Glycogenic   degeneration   of  leucocytes, 

499 

Glycerine  and  belladonna  in  chilblain,  1 83 
Golding  Bird's  apparatus  for  flat  foot,  307 
Gonococcus  vaccine,  dose  of,  517 
Gonorrhoeal  flat  foot,  307 

warts,  treatment  of,  239 
Gooch  splinting  after  osteotomy,  369,  381 
( lowers'  haemoglobinometer,  500 
Graduated  compress,  109 
Granulating  flaps  in  plastic  operations, 
1 60 

wounds,  treatment  of,  165 
Granulation,  healing  by,  129 

tissue,  2,  129 

Granulations,  healing  by  union  of,  131 
Grieg  Smith's  pressure  forceps,  no 
Guaiacol  in  tuberculosis,  232 


H/EMOCVTOMETER,  Thoma's,  491 
Haemoglobin,  estimation  of,  500 


Haemoglobinometer,  Cowers',  500 

Haldane's,  500,  501 
Haemolysis  of  red  blood-cells,  505 
Haemorrhage,  104-117 
arterial,  104 
capillary,  105 
in  operations,  104 
means  of  controlling,  106 

adrenalin  chloride  in,  in 
bloodless  method,  objections  to, 

107 

calcium  lactate  in,  in 
cautery,  108 
cold,  no 

Crile's  clamps,  107,  108 
drugs,  in 

Ksmarch's  bandage,  K"> 
graduated  compress,  109 
heat,  m 

Horsley's  wax,  110 
infusion  of  saline  solution,  112 
iron,  perchloride  of,  in 
Leiter's  tubes,  in 
ligature,  permanent,  108 
temporary,  107 
Lister's  method,  107 
pressure,  109 

temporary,  by  forceps,  no 
torsion,  108 

saline  solution,  infusion  of,  112 
per  rectum,  115 
subcutaneous,  115 
styptics,  in 
tourniquets,  106 

mode  of  spontaneous  arrest  of,  105 
symptoms  of  severe,  112 
venous,  105 

Haemorrhagic  ulcer,  characters  of,  44 
Hahn's  tracheotomy  tampon  and  chloro- 
form attachment,  469 
Haldane's  haemoglobinometer,  500,  501 
Hallux  flexus,  286 
rigidus,  286 
valgus,  279 

bunion,  27<) 
treatment  of, 

early  stage,  281 
operative,  283 
severe  cases,  283 
Halsted's  intradermic  suture,  138 
Hammer  toe,  275 
causes  of,  275 

pathological  changes  in,  276 
treatment  of,  277 

after-treatment,  279 
appliances  in,  277 
ligaments,  division  of,  277 
phalanx,   excision   of   head   of 

first,  278 

tenotomy  in,  277,  278 
T-shaped  splint  in,  277 
varieties  of,  275 
Hands,  disinfection  of,  101 


538 


INDEX 


'  Hard  '  chancre,  209 
Hard  fibroma,  251 

Healing,  modes  of,  chap.  vi.  127-131 
by  blood-clot,  129 
first  intention,  127 

conditions  inimical  to,  128 
granulation,  129 
union  of  granulations,  131 
under  a  scab,  129 
signs  of,  in  ulcers,  42 
Heart,  acu-puncture  of,  477 

galvano-puncture  of,  477 
Heat  in  acute  inflammation,  1 1 

as  a  means  of  controlling  haemor- 
rhage, in 

in  treatment  of  shock,  120 
Hectic  fever,  190 

general  treatment  of,  192 
lardaceous  disease  in,  190 
local  treatment  of,  190 
operations  in,  191 
waxy  degeneration  in,  190 
Hereditary  syphilis,  226 
Heredity  as  a  factor  in  production  of 

tuberculosis,  229 

Hewitt's  gas  and  oxygen  apparatus,  451 
Hilton's  method    of    opening  an   acute 

abscess,  28 

Hip,  congenital  dislocation  of,  393-402 
pathology,  393 
treatment  of,  395 
operative,  400 
Hodgkin's  disease,  blood-count  in,  496, 

498 
Hollow  club-foot  (pes  cavus),  312,  322, 

334 

Home  exercises,  424 
Horns,  240 

Horsehair  sutures,  95,  136 
Horsley's  wax,  no 
'  Hunterian  '  chancre,  209 
Hutchinson's  formula  for  mercurial  pill, 

219 

Hyaline  cells  of  blood,  497 
Hydatid  disease,  blood  count  in,  508 
Hydroceles,  265 
of  neck,  264 
Hydro-nephrosis,  265 
Hygiene  in   treatment   of   tuberculosis, 

231 

Hyperplasia,  definition  of,  237 
Hypodermic  injections 

for  local  anaesthesia,  485 
of  cocaine,  483 

preparatory  to  anaesthesia,  445 
Hysteria  in  relation  to  club-foot,  313 


ICE-BAG  in  acute  inflammation,  9 
precautions  in  applying,    10 
Ichthyol  in  treatment  of  erysipelas,  198 
Immune  body,  509 
Imperfect  innervation,  gangrene  from,  76 


Imperial  drink,  15 

in  septic  intoxication,  187 
traumatic  fever,  188 

Incised  wounds,  chap.  vii.  132-167 
after-progress  of,  152 
apposition  of  the  edges  in,  133 
approximation  of  deeper  structures, 

133 

avoidance  of  irritation  in,  145 

movement  in,  144 
classification  of,  132 
drainage  of,  147 
dressings  for,  150 
exclusion  of  micro-organisms  from, 

132 
made  by  surgeon  through  unbroken 

skin,  132 

Michel's  clips  in,  138 
pressure  in,  151 
sutures  in,  136 

buried,  137 

button,  140 

button-hole,  142 

chromicised  catgut,  93 

coaptation,  142 

continuous,  142 

Halsted's  intra-dermic,  138 

how    to    avoid    stitch    marks, 

137,  138 

Lister's  needle  for  silver  wire,  1 40 
materials  for, 

when  there  is  great  tension,  139 
when     there      is      moderate 

tension,  141 

when  there  is  no  tension,  136 
removal  of,  143 
silk,  143 

silkworm  gut,  142 
stitches  of  coaptation,  142 
relaxation,  140 
sulpho-chromic  catgut,   93 
wire,  140 
treatment  of, 

Barker's  flushing  spoon  in,  156 
inflicted    accidentally,    163 

scalp  wounds,  164 
plastic  operations,  157 
skin  grafting,  157 
where  asepsis  cannot  be  kept, 

161 
where    edges    have    not    been 

brought  together,    157 
where  sepsis  has  occurred,  155 
where  sinuses  are   present,  166 
without  antiseptics,  153 
undermining  flaps  in,  140,  157,  158 
Incision,    exploratory    for    diagnosis    of 

nature  of  tumours,  245 
Incisions  in 

acute  inflammation,  8 
chronic  inflammation,  21 
diffuse  cellulitis,  31 
phlegmonous  erysipelas,  199 


INDEX 


539 


Indirect  gangrene,  72 
Infantile  paralysis 

as  cause  of  genu  valgum,  371 

talipes  calcaneus,  335 
cavus,  334 
equino-varus,  345 
equinus,  321 
valgus,  342 
varus,  344 

Infection,  aerial,  avoidance  of,  104 
of  wounds,  99 
septic,  of  wounds,  160 
Infective   diseases  of   wounds,  chap.  ix. 

185-203 
erysipelas,  197 
hectic  fever,  191 
pyaemia,  acute,  192 

chronic,  195 
septic  intoxication,  185 
septicaemia,  acute,  189 

chronic,  190 
tetanus,  199 
traumatic  fever,  188 
gangrene,  82 

Infiltration  anaesthesia,  485 
Inflamed  ulcer, 

characters  of,  43 

special  points  in  treatment  of,  61 
Inflammation,  definition  of,  I 

acute,  and  its  sequelae,  chap.  i.  1-24. 
arterial  congestion  in,  13 
Bier's  method  of  treatment,  13 
blood-letting  in,  4 
general,  4 
local,  5 

cause,  removal  of,  3 
changes  in,  i,  2 
cold  in,  8 

cupping,  dry,  and  wet,  7 
drinks  in,  15 
drugs  in,  15 

evaporating  lotions  in,  9 
fomentations  in,  12 
food  in,  15 
free  incisions  in,  8 
general  symptoms  of,  2 
heat  in,  1 1 
ice-bag  in,  9 
lead  lotion  in,  9 
leeches,  5 

bleeding  from  bites  of,  6 
precautions  in  using,  5 
Leiter's  tubes  in,  10 
local  changes  in,  i 

treatment  of,  4 
pathology  of,  i 
position  in,  4 
poultices  in,  1 1 
prognosis  of,  15 
purgatives  in,  14 
resolution  in,  2 
results,  i 
scarification  in,  8 


Inflammation,  acute, 

spongiopilin  in,  13 
symptoms  of,  2 
treatment  of,  3-15 
turpentine  stupes  in,  13 
venous  congestion  in,  13 
chronic,  16-24 

as  factor  producing    tubercu- 
losis, 229 
blisters  in,  19 
causes  of,  16 

changes  in  the  tissues,  16 
counter-irritation  in,  18 
by  actual  cautery,  20 
blisters,  19 
croton  oil,  20 
iodine,  19 
mustard,  19 
free  incisions  in,  21 
general  treatment  of,  24 
local  treatment  of,  18-24 
massage  in,  23 
pathology  of,  16 
position  in,  18 
pressure  in,  22 
removal  of  cause  of,  18 
rest  in,  18 

Scott's  dressing  in,  23 
strapping  in,  22,  23 
symptoms  of,  17 
treatment  of,  18 
Infusion,  saline,  112 
Inhalers  for  administering 
anaesthetic  mixtures,  465 
anaesthetics, 
Allis's,  454 
Clover's,  453 
Junker's,  459 
Schimmelbusch's,  459 
Vernon-Harcourt's,  463 
Injury    as   a   cause   of   talipes   equino- 
varus,  345 

as  a  factor  in  production  of  tubercu- 
losis, 228 
Inoperable  malignant  disease,  treatment 

of,  248 

anodynes,  250 
Coley's  fluid,  249 
oophorectomy,  250 
radium,  249 
thyroid  extract,  250 
vaccines,  249 
X-rays,  249 
Instep,  artificial,  303 
Instillations  of  cocaine,  483 
Instruments,  sterilisation  of,  92 
Intensive  method  of  administering  tuber- 
culin, 524 
Intoeing,  311 
Intoxication,  septic,  185 
Intra-cranial  operations,  administration 

of  anaesthetics  in,  467 
Intra-muscular  injection  of  mercury,  222 


540 


INDEX 


Intravenous  saline  infusion,  112 
Inunction  of  mercury,  220 
Iodide  of  iron  in  tuberculosis,  232 
potassium  in 

hereditary  syphilis,  226 
tertiary  syphilis,  224 
Iodine,  counter-irritation  by,  19 
disinfection  of  skin  by,  100 
in  treatment  of  erysipelas,  198 
irrigation  of  wounds  by,  33 
reaction  of  leucocytes,  499 
lodoform,  in  wounds  of  mucous  mem- 
branes, 162 
in  septic  wounds,  161 
lodoform  emulsion,  234 

in  tuberculous,  abscess,  234,  235 
Iron,  in  primary  syphilis,  218 

ulcers,  61 

Irrigation,  in  diffuse  cellulitis,  32 
in  phlegmonous  erysipelas,  199 

septic  infection,   186 
of  wounds,  155 
Irritable  ulcer,  characters  of,  43 

treatment  of,  62 
Irritation,  avoidance  of,  in  wounds,  145 


JENNER'S  method  of  staining  leucocytes, 

497 
Jones's,  Dr.  Lewis,  bipolar  fork  electrode, 

257,  258 

Junker's  inhaler,  459 
with  tube,  468 


KANGAROO  tendon,  use  of,  95 

Knock    knee    (see    also    Genu    valgum), 

371-383 

Kraske's  treatment  of  erysipelas,  198 
Kyphosis,  403 


LACERATED  wounds,  170 

amputation  for,  question  of,  171 
causes,  170 
characters,  170 
treatment  of,  171 
Lactate    of    calcium    in     haemorrhage, 

in 

Lardaceous  disease,  190 
Large  hyaline  cells,  497 

mononuclear  cells,  497 
Lateral  curvature  of  the  spine,  405 
Lawson  Tait's  pressure  forceps,  109 
Lead  buttons,  use  of,  140 
lotion,  9 

in  erysipelas,  199 
Lead  and  opium  lotion,  9 
Leech-bites,  arrest  of  bleeding  from,  6 
Leeches,  application  of,  5 
precautions  in,  6 
mode  of  detaching,  6 
Leech-glasses,  5 


Leiter's  tubes  in  acute  inflammation,  10 
dangers  of,  10 
in  haemorrhage,  in 
Leucocyte  count,  differential,  496 
Leucocytes,  enumeration  of,  490 
iodine  reaction  of,  499 
Jenner's  method  of  staining,  497 
polynuclear,  497,  498 
Leucocytosis,  494,  495,  496 
Leucopenia,  495 
Ligaments,  division  of, 

in  congenital  club-foot,  319,  351 
cuneiform  tarsectomy,  359 
excision  of  the  astragalus,  332 
talipes   equino-varus,    351 
shortening  of,  in  club-foot,  313,  345 
Ligature  in  haemorrhage,  107,  108 
Ligatures,  disinfection  of,  93,  94,  95 
materials  for,  93,  108 
permanent,  108 
temporary,  107 

Linear  osteotomy  of  tibia,  368 
Linseed  meal  poultices,  n 
Lipoma,      diffuse     and     circumscribed, 

251,  252 

Liquid  air,  in  treatment  of  naevi,  262 
Lister's  cyanide  gauze,  96,  151 

method  of  controlling  haemorrhage, 

107 

preparing  catgut,  93 
needle  for  wire  sutures,  139,  140 
Local  anaesthesia,  480-486 
advantages  of,  480 
conduction  anaesthesia,  485 
methods  of  producing,  480 
freezing,  482 
infiltration,  485 
injection,  484 
instillation,  483 
painting  surface,  484 
spraying,  483 

Lorenz's    treatment    of    congenital    dis- 
location of  hip,  395 
Lotions,  evaporating,  9 
Lupus  anatomicus,  172 
Lymphadenoma,  264 

blood-count  in,  507 
Lymphangiomata,  264 
cavernous,  264 
cystic,  264 
simple,  264 
Lymphatic   leucocythaemia,  blood-count 

in,  498,  507 

Lymphatics,  removal  of,  in  carcinoma,242 
Ljtnphocytes,  497,  498 
Lymphosarcoma,  264 

MACEWEN'S  osteotomy  for  genu  valgum, 

377 

Mackintoshes,  employment  of,  in  opera- 
tions, 102 

Macrocytes,  507 

Malaria,  blood-count  in,  508 


INDEX 


Malignant  disease,  blood-count  in,  507  . 
tumours,  definition  of,  238 
carcinomata,  241 
enclotheliomata,  243 
sarcomata,  243 
treatment  of, 

general  points  in,  245 
exploratory      incision      for 

diagnosis,  245 
inoperable  cases,  248 
operations  upon,  246 
Manipulations, 

in  bow-legs,  366 

congenital  club-foot,  316 

dislocation  of  the  hip, 

395 

curved  tibia  and  fibula,  366 
genu  valgum,  373 
talipes  equino-varus,  347 

valgus,  342 

Martin's  india-rubber  bandage,  48 
Mask,  metal  for  A.C.E.,  465 
Massage,  automatic,  24 
friction,  23 
in  bow-legs,  365 
cellulitis,  37 

chronic  inflammation,   23 
congenital  club-foot,  316 

dislocation  of  the  hip,  395 
curved  tibia  and  fibula,  365 
genu  valgum,  373 
gonorrhceal  flat-foot,  302 
metatarsalgia,  288 
scoliosis,  417 
talipes,  316 

calcaneus,  335 
equino-valgus,  342 
varus,  346 
tuberculosis,  232 
ulcers,  47 

paralytic,  64 
from  cold,  183 
principles  of,  23 
Mast  cells  of  blood,  497 

chronic  inflammation,  16 
Megaloblasts,  507 
Melanotic  cancer,  242 

sarcoma,  244 
Mercury, 

administration  of,  in  syphilis,2 18-224 

length  of  time  of,  225 
fumigation  by,  222 
'  C.ibcrt's  syrup,'  220 
'  Hutchinson's  formula,'  219 
intra-muscular  injections  of,  222 
inunction  of,  220 
length  of  treatment  by,  225 
modes  of  administration  of, 

in  hereditary  syphilis,  226 
primary  (local)  syphilis,  217 
secondary  syphilis  218, 
tertiary  syphilis,   224 
pills  of,  219 


Metatarsalgia,  anterior,  287 
Method  of  spread  in  carcinomata,  2  \i 
Michel's  clips,  138 

Micrococcus  neoformans,  vaccine  of,  249 
Microcytcs,  507 

Micro-organisms,     exclusion     of,     from 
wounds,  99 

sources  of  infection  by,  99 
Mixtures,  anaesthetic,  463 

A.C.E.,  463 

Billroth's,  463 

chloroform  and  ether,  464 

Vienna,  463 
Moist  dressings  in  diffuse  cellulitis,  35 

gangrene,  67 
Moles,  251 

Molluscum  fibrosum,  251 
Mononuclear  cells,  large,  497 
Morphine  in  shock,  122 

in  tetanus,  203 

preliminary  injection  before  anaes- 
thesia, 444 
with  atropine,  445 
with  scopolamine  445 
Morton's  neuralgia,  287 
Mouth  gag,  475 

Mucous      membranes,      treatment      of 
wounds  of,  161 

patches,  treatment  of,  224 
Muscular  exercises,  scheme  of,  423-439 
Mustard,  counter-irritation  by,  19 
Myeloid  sarcoma,  244 
Myoma,  254 
Myxoma,  250 


N/T.VUS,  capillary,  255 

cavernous  or  venous,  255 
treatment  of, 

carbolic  acid  in,  260 
carbonic  acid,  solid,  in,  262 
caustics  in,  259 
cauterisation  of,  261 
electrolysis  in,  256 
ethylate  of  sodium  in,  260 
excision  in,  255 
freezing  in,  262  t 
liquid  air  in,  262        | 
radium  in,  264  4 
temporary  strangulation  of,  259 
Neuritis,  a  cause  of  ulcers,  41 
Neuromata,  254 
Nicoladoni's  operation,  340 
Nitrate  of  silver  in  erysipelas,  198 
in  irritable  ulcer,  62 

weak  ulcer,  62 
Nitric  acid  in  cancrum  oris,  85 

in  phagedenic  ulcers,  63 
Nitrous  oxide,  administration  of,  448 
after  effects  of,  451 
apparatus  and  administration,  449 
cases  suitable  for,  449 


542 


INDEX 


Nitrous  oxide,  combined  with  ether,  457 
complications  during  administration 

of,  450 

limitations  to  use  of,  449 
method    of    producing     prolonged 

anaesthesia  by,  451 
phenomena    during    administration 

of,  450 

preparation    and    position    in    ad- 
ministration of,   449 
properties  of,  448 
Noma,  85 

Nose  and  mouth,  anaesthetics  in  opera- 
tions upon,  467 

Novocaine  as  a  local  anaesthetic,  484 
Nutrient  enema,  121 
Nux  vomica  in  tuberculosis,  232 


(EDEMA  TO  us  ulcer,  treatment,  62 
Ogston's  operation  for  flat-foot,  309 
Oophorectomy  for  inoperable  malignant 

disease,  250 

Open  method  of  administering  ether,  454 
wounds,  occurrence  of  sepsis  in,  160 
granulating   wounds,  treatment  of, 

165 

Opening  an  abscess,  method  of,  27 
Operating  room  in  a  house,  91 
tables,  91 
theatres,  89 

Operations,  after-treatment  of,  124 
aperients  after,  126 
before,  88 
avoidance  of  aerial  infection  during, 

104 

classification  of,  87 
dangers  of,  how  guarded  against,  99 
disinfection  of  the  hands,  101 

skin,  99 

entry  of  air  into  veins  during,  122 
feeding  after,  125 
before,  88 

for  malignant  tumours, 
palliative,  248 
partial,  247 
radical,  246 
gloves,  101 
haemorrhage  during,  and  its  arrest, 

104-112 

symptoms  of  severe,  112 
local,  in  hectic  fever,  191 
mackintoshes  in,  102 
management  of  sponges  during,  104 
mental  attitude  of  patient  before,  88 
most  favourable  time  for,  88 
pain  after,  126 
pneumatic  suit  for,  120 
precautions  during,  102 

in  dressing  wounds  after,  150 
preparation  of  dressings,  96 

instruments,   92 
ligatures,  93 


Operations,  preparation  of  patient  for,  87 
sponges,  95 
swabs,  96 

selection  of  room  for,  91 
shock  during,  117-122 
sources     of     infection     by     micro- 
organisms, 99 
surgeon's  dress  for,  102 
syncope  during,  123 
Opisthotonos  in  tetanus,  200 
Opium  in  gangrene,  74,  8 1 
Opsonic  index,  503,  518—520 
Os  calcis,  eversion  of,  in  equino-varus,  344 
Osteitis  deformans,  363 
Osteo-malacia,  363 
Osteomata,  ivory,  253 
of  skull,  254 
spongy,  253 
Osteo-plastic   operations    for    club-foot, 

358 

Osteo-sarcoma,  244 
Osteotomy,  cuneiform,  368 
linear,  368 
Macewen's,  377 
oblique,  369,  384 
sub-trochanteric,  390 
of  femur,  377,  380,  384 
femur  and  tibia,  381 
tibia,  367,  368,  369,  381,  384 
plaster  of  Paris  after,  381 
Oval  wounds,  plastic  operations  for,  157 
Ovary,  cysts  of,  265 
Oxygen  in  anaesthesia,  451 

carbonic  oxide  poisoning,  177 


PAIN,  after  operations,  125,  126 
influence  of,  on  shock,  122 
Painful  cicatrix,  206 
Palmar  fascia,  contractions  of,  289 

operations  for,  291 
Papillomata,  treatment  of,  239 
Pappenheim's  stain,  18 
Paralytic  club-foot,  313  (see  also  Talipes) 
ulcer,  characters  of,  45 
electric  bath  in,  64 
electricity  in,  64 
massage  in,  64 
special  points  in  the  treatment  of, 

64 

Parasites  in  wounds,  185 
Parker's  operation  of  syndesmotomy,  351 
Passive  motion  in  diffuse  cellulitis,  37 
Paterson's     apparatus     for     prolonged 

nitrous  oxide  anaesthesia,  451 
Pathology  of  inflammation,  i 
tuberculosis,  230 
Perforating  ulcer  of  the  foot,  45 

treatment,  of,  65 
Periphlebitis,  suppurative,  194 
Pernicious  anaemia,  blood-count  in,  507 
Peronei  tendons,  tenotomy  of,  343 
Peroxide  of  hydrogen,  31,  155 


INDEX 


543 


Pes  cavus,  312,  334 

partial  tarsectomy  for,  334 
Petrissage  in  massage,  23 
Phagedena,  84 
Phagedenic  chancre,  treatment  of  acute, 

217 

gangrene,  84 
ulcer,  characters  of,  44 

treatment  of,  63 
Phagocytosis,  197 

Phelps'  operation  for  club-foot,  356 
Phenacetin,    use    of,    in    treatment    of 

pyaemia,  194 
Phlegmonous  erysipelas,  197 

treatment  of,  199 
Picric  acid  in  burns,  179 
Pituitary  extract  in  shock,  121 
Plantar  fascia,  division  of,  329,  351 
Plasma  cells,  16,  17 
Plaster  of  Paris  after  osteotomy,  381 
Plastic  operations,  157 

by  curved  incisions,  159 
granulating  flaps,  160 
for  oval  wounds,  157 

quadilateral  wounds,  158 
triangular  wounds,  159 
undermining  flaps  in,  158 
Pneumococcus  vaccine,  dose  of,  517 
Pneumatic  suit,  Crile's,  120 
Poikilocytes,  507 
Poisoned  wounds,  172 
treatment  of,  172 
Poisoning  by  carbonic  oxide,  176 
Polynuclear  leucocytes,  497,  498 
'  Polyvalent '  serum,  173 
Position  in  treatment  of 
acute  inflammation,  4 
chronic  inflammation,  18 
diffuse  cellulitis,  36 
ulcers,  47 
Post-mortem  warts,  172 

wounds,  172 

Potassa  fusa  in  phagedenic  ulcer,  63 
Poultices  in  acute  inflammation,  n 
charcoal,  n 
mustard,  19 

Pressure,  gangrene  due  to,  70 
in  arrest  of  bleeding,  109 
chronic  inflammation,  22 
ulcers,  47 
wounds,  151 
ulcer,  characters  of,  44 

special    points    in    treatment 
of,  64 

Pressure-forceps,  types  of,  109 
Primary  chancre,  209 
'  Primary  syphilis,'  local  treatment  of, 

217 
Prophylaxis  in  treatment  of, 

acute  traumatic  gangrene,  83 
bedsore,  70 
phagedena,  84 
senile  gangrene,  73 


'  Proud  '  flesh,  44 

Psoas  abscess,  treatment  of,  235 

Punctured  wounds,  168 

Pus,  characters  of,  25 

Pyaemia,  acute,  192 

chronic,  195 
pathology  of,  193 
symptoms  of,  192 
treatment  of,  193 

antipyrin  in,  194 

diet  in,  195 

drugs  for,  194 

local,  193 

phenacetin  in,  194 

quinine  in,  194 

removal  of  thrombosed  vein  in, 

193 

salicylate  of  soda  in,  194 
saline  injections  in,  195 
sponging  in,  195 
stimulants  in,  195 
vaccines  in,  195 


QUADRILATERAL  wounds,  plastic  opera- 
tions for,  158 

Quinine  in  general  septic  infection,  189 
pyaemia,  194 


RACHITIS  ADOLESCENTIUM,  386 
Radium  burns,  174 

in  inoperable  malignant  disease, 

249 

in  treatment  of 
nasvi,  264 
rodent  ulcer,  249 
superficial  epithelioma,  243 
Radius,    operation    on,    in    club-hand, 

362 

Raynaud's  disease,  76 
electric  bath  in,  77 
electricity  in,  77 
cold  in,  77,  78 
friction  in,  78 
general  treatment  of,  79 
shampooing  in,  78 
treatment  of,  77-79 
Rectal  saline  infusion,  115,  121 
Red    blood   corpuscles,    estimation    of, 

499 

'  Red  lotion,'  62 
Resection  of  the  tarsus,  357,  358 

tibia  and  fibula,  320 
Resolution  in  inflammation,  2 
Respiratory  troubles  during  anaesthesia, 

471 
Rest  in  chronic  inflammation,  18 

diffuse  cellulitis,  36 

scoliosis,  416 

treatment  of  ulcers,  46 

tuberculosis,  232 
Reverdin's  method  of  skin-grafting,  52 


544  INDEX 

Rheumatic  flat-foot,  301  Scirrhus,  atrophic,  241 

Rickets,  363,  372,  375,  403  Scoliosis,  405-423 

as  cause  of  bow-legs,  363  causes  of,  405 

curvature  of  the  neck  of  inequality  of  length  of  supports 

the  femur,  386  of  spine,  405 

genu  valgum,  372  inequality  of  weight  borne  on  the 

varum,  383  two  sides  of  the  spine,  406 

scoliosis,  407  secondary  to  other  affections  of 

clothing  for  patients  with,  365  spine  or  thorax,  407 

dietetic  treatment  for,  363  weakness  of  the  spinal  muscles, 

drugs  in  treatment  of,  365  406 

feeding  in,  363  examination,  method  of,  409 

hygienic  treatment  of,  365  pathological  changes  in,  407 

in  connection  with  club-foot,  314  prognosis  of,  411 

Paddington  Green  Hospital  dietary,  symptoms,  objective,  407 

363  subjective,  408 

'  rachitis  adolescentium,'  386  treatment,  412 

Rickety  curvature  of  tibia,  363  in  adolescence,  417 

Risus  sardonicus,  200  general      indications      for, 

Rodent  ulcer,  241,  417 

treatment  by  radium,  249  when  curve  can  be  obliter- 

X-rays,  249  ated,  418 

Round-celled  sarcoma,  244  apparatus,  420 

exercises,  418 
posture,  419 
supports,  421 

SACRO-COCCYGEAL  tumours,  265  when    curve    can    be    im- 

Salicylate     of    soda    in     treatment     of  proved  but  not  ob- 

pyaemia,  194  literated,  421 

Salicylic  collodion,  239  exercises,  421 

Saline  infusion,  intra- venous,  112,  121  spinal  supports,  421 

rectal,  115,  121  when  curve  cannot  be  di- 

sub-cutaneous,  120,  121  minished, 

Salvarsan  ('  606'),  212  exercises,  423 

Saprophytes  in  wounds,  185  spinal  supports,  423 

Sarcoma,  243  in  adults,  423 

prognosis  of,  245  in  childhood,  415 

symptoms  of,  243  exercises,  416 

treatment  of,  245  medicinal,  416 

amputation  in,  244  massage,  417 

varieties  of,  recumbency,  416 

alveolar,  244  removal  of  cause,  415 

chondro-,  244  in  infancy,  415 

melanotic,  244  Scott's  dressing  in  chronic  inflammation, 

myeloid,  244  23 

osteo-,  244  Sebaceous  cysts,  265 

round-celled,  244  Secondary  shock,  186 

spindle-celled,  244  syphilis, 

Sayre's    apparatus  general  treatment  of,  218 

after  tenotomy   of   tendo   Achillis,  local  treatment  of,  224 

327  Seegen's  dietary,  80 

for  talipes  equino-varus,  348,  352  Senile  gangrene,  72 

Scab,  healing  under  a,  129  prophylactic  treatment  of,  73 

Scalds,  174  question  of  amputation  in,  74 

Scalp  wound,  treatment  of,  164  symptoms  of,  73 

Scapula,  congenital  elevation  of,  297  treatment  of,  73 

Scarification  in  acute  inflammation,  8  Sepsis    as    a    factor    in    production    of 

of  scar  in  cheloid,  205  tuberculosis,  229 

Scarpa's  shoe,  354  in  open  wounds,  160 

Schimmelbusch's  inhaler  for  chloroform,  wounds,  treatment  of,  155 

459  Septic  diseases  of  wounds,  chap.  ix.  185- 

Schleich's  method  of  infiltration  anaes-  203 

thesia,  485  infection,  local  and  general,  173 


INDEX 


545 


Septic  intoxication,  185 
ammonia  in,  187 
brandy  in,  187 
digitaline  in,  187 
drainage  tubes  in,  187 
ether  in,  187 
general  treatment  of,  187 
irrigation  in,  186 
local  treatment  of,  186 
strychnine  in,  187 
symptoms  of,  186 
post-mortem  wounds,  173 
sinuses,  treatment  of,  166 
wounds,  165 
Septicaemia, 

acute,  173,  189 

amputation  in,  190 
blood-count  in,  506 
pathology  of,  189 
symptbms  in,  189 
treatment  of,  189 
chronic,  190 

amputation  in,  191 
local  treatment  of,  191 
Serum,  anti-streptococcic  (see  Anti-strep- 

tococcic  serum) 
freezing  point  of,  504,  505 
Sex  as  a  factor  in  the  production  of 

tuberculosis,  229 

Shampooing  in  Raynaud's  disease,  78 
Shields,  celluloid,  in  treatment  of  ulcers,  52 
Shock,  effect  of  anaesthetic  on,  118 
influence  of  pain  on,  122 
pathology  of,  117 
secondary,  186 
treatment,  prophylactic,  118 

when  established,  120 
surgical,  in  relation  to  anaesthesia,  479 
symptoms  of,  118 
Sickness  after  anaesthesia,  478 
Silicate  bandage,  285,  287,  370 
Silk  ligatures,  94 
sutures,  143 

Silkworm  gut  sutures,  94,  142 
Silver  wire  sutures,  95 
Simple  lymphangiomata,  264 
tumours,  definition  of,  238 
ulcer,  characters  of,  43 

special  points  in  treatment  of,  61 
Sinuses,  septic,  treatment  of,  166 
Skin,  disinfection  of,  99,  100 
Skin-grafting,  52 

in  treatment  of  burns,  179 
Reverdin's  method,  52 
Thiersch's  method,  157 
after-treatment,  58 
cutting  the  grafts,  53,  54 
dressing  the  grafts,  56 
in  fresh  wounds,  157 
ulcers,  53 

lacerated  wounds,  171 
preparation  of  ulcer  for,  53 
Skinner's  inhaler,  454 
Skull,  exostosis  of,  254 

I. 


Smoking,   prohibition   of,  in  secondary 

syphilis,  218 
Soft  fibroma,  251 

Spencer  Wells's  pressure-forceps,  no 
Spinal  anaesthesia,  8 1,  1 80,  486 
after-effects  of,  489 
Barker's  solution  for,  487 
cases  suitable  for,  486 
difficulties  in,  488 
method  of  producing,  487 
braces,  421 
curves,  407 
supports,  421,  423 
Spindle-celled  sarcoma,  244 
Spine,  curvature  of,  chap.  xxi.  403-423 
angular,  403 
kyphosis,  403 
lateral,  405 
scoliosis,  405 
Spirochaeta  pallida,  209 
Spleno-medullary  leucocythaemia,  blood 

count  in,  498,  507 
Splints, 

after  cuneiform  tarsectomy,  360 
Didot's  operation,  274 
operation  in  Dupuytren's  con- 
traction, 292,  293 
for  congenital  club-foot,  317 
genu  recurvatum,  385 
talipes,  317 
Gooch's  369,  382 
in  after-treatment   of   bifid   finger, 

270 
bow  legs,  duration  of  use  of,  after 

operation,  370 
curved  tibia  and  fibula,  366 
genu  valgum,  375 

after  operation  on,  383 
genu  varum,  360 
hallux  valgus,  282,  284 
hammer  toe,  277 
Phelps'  operation,  356 
talipes  calcaneus,  335 

equino-varus,  347,  348, 352 
Sponges,  management  of,  in  operations, 

104 

preparation  of,  95 
Sponging  in  acute  septicaemia,  189 

pyaemia,  195 

Spongiopilin  in  acute  inflammation,  13 
Spongy  exostosis,  253 
Spontaneous     arrest     of     bleeding     in 

operations,  105 
Spray,  ether,  482 
Squamous  epithelioma,  241 
Staphylococcus  pyogenes,  25 

vaccine,  dose  of,  517 
Stasis,  white,  13 
Status  lymphaticus,  471 
Sterilisation  of  dressings,  97 

instruments,  92 
ligatures,  93,  94,  95 
sponges,  95 
swabs,  96 

NN 


546 


INDEX 


Steriliser  for  dressings,  steam,  97 
Sthenic  inflammatory  fever,  3 
Stimulant  applications  for  weak  ulcers,  62 
Stimulants,  use  of, 
in  pyaemia,  195 

septic  intoxication,  187 
shock,  120,  121,  479 
Stitches  of  coaptation,  142 

relaxation,  139,  140 
Stitchmarks,  how  to  avoid,  136,  137,  138 
Stokes's  operation  for  flat  foot,  310 
Stovaine  as  an  anaesthetic,  484 

in  spinal  anaesthesia,  487 
Strapping,  in  chronic  inflammation,  23 

treatment  of  ulcers,  47 
Streptococcus  pyogenes,  25,  31,  189,  193, 
197 

vaccine,  dose  of,  517 
Strong  mixture,  50,  100 
Strychnine,  injection  before  anaesthesia, 

119,  443,  445 
in  septic  intoxication,  187 

shock,  119,  121 
Stupe,  turpentine,  13 
Styptics  for  control  of  haemorrhage,  1 1 1 
Subcutaneous  division  of  palmar  fascia, 

291 

injection  of  tuberculin,  521 
saline  infusion,  120,  121 
Sub-trochanteric  division  of  femur,  390 
Sulpho-chromic  catgut  ligatures,  93 
Sulphur  baths  and  spas  in  treatment  of 

syphilis,  225 

Suppuration,  acute,  chap.  ii.  25-38 
blood-count  in,  506 
causes  of,  25 

circumscribed  abscess,  27 
diffuse  cellulitis,  31 
extension,  mode  of,  26 
Suppurative  periphlebitis,  194 
Surgeon's  dress  during  operations,  102 
Sutures  buried,  137 
button,  140 
button-hole,  142 
continuous,  142 
deep,  133 
Halsted's,  138 
interrupted,  142 
intra-dermic,  138 
materials  for,  93 
removal  of,  143 
where  there  is  great  tension,  139 

moderate  tension,  141 
no  tension,  136 
Swabs,  preparation  of,  96 
Sylvester's  method  of  artificial  respira- 
tion, 476 

Syncope  during  anaesthesia,  471 
operations,  123 
treatment  of,  123 
Syndesmotomy,  351 

Syphilitic  curvature  of  tibia  and  fibula, 
363 


Syphilis,  chap.  xi.  209-227 
acquired,  209-226 

blood-count  in,  506 
primary  stage,  209 

general  treatment,  218 
iron,  218 
mercury,  216 
salvarsan  ('606'),  212 
local  treatment,  217 
secondary  stage,  210 

general  treatment,  218 
care  of  teeth,  218 
condylomata,  224 
diet,  218 

mercury  in,  218-224 
length  of  treatment 

by,  225 

prohibition    of    smok- 
ing, 218 

local  treatment,  224 
of  condylomata,  224 
mucous  patches,  224 
rash,  224 
tertiary  stage,  211 

general  treatment,  224 
local  treatment,  224 
mercury  in,  224 
hereditary,  treatment  of,  226 
iodide  of  potassium  in,  226 
mercury  in,  2?.6 
salvarsan  ('606')  in,  227,  216 
prophylaxis      in       treatment       of, 

211 

salvarsan  ('  606  ')  in  treatment  of, 

212 

sources  of  infection  in,  211 
sulphur  baths  and  spas  in,  225 
Wassermann  reaction  in,  210,  508, 

5io 
value  of,  226,  513 

TALIPES  (see  also  Club-foot) 
acquired,  313 

general  points  in  treatment  of, 

319 

causes,  312 
congenital,  312 

general  points  in  treatment  of, 

315 

definition,  312 
pathological  changes  in,  313 
splints  for,  317 
varieties  of,  312 

calcaneo-valgus,  312 
calcaneus,  312,  335 
definition  of,  312 
treatment  of,  335 
arthrodesis,  341 
faradic  current  in,  335 
massage  in,  335 
muscle     and     tendon 
transplantation,  340 
splint  in,  335 


INDEX 


547 


Talipes,  varieties  of, 

calcaneus,  treatment  of, 
tendo  Achillis, 

plastic  operations  on, 

337 

shortening  of,  336,  337 
transplantation  of ,  339 
"L -shaped  section  of, 

338 

walking  apparatus  in,  336 
cavus,  334 

in  connection  with  equinus, 

322,  334 

equino-valgus,   312,  344 
equino-varus,  312,  344 

astragalus,  changes  in,  345 
bones,  changes  in,  345,  355 
causes  of,  345 
ligaments,  changes  in,  345 
muscles,    contractions    in, 

346 
obstacles   to  reduction   in 

severe  cases,  350,  355 
pathological    changes    in, 

345 

stages  in  rectification   of, 

350 
structures    which     oppose 

reposition  of  foot,  346 
treatment  of,  346 
amputation,  358 
apparatus  for,   347 
astragalus,  removal  of, 

358 

boots  in,  355,  361 
correction  of  equinus, 

350 
cuneiform  tarsectomy 

in,  358 

division  of  flexor 
longus  digitorum, 
350 

plantar  fascia,  351 
tendo       Achillis, 

350,  353,  361 
tibiales     tendons, 

350 
duration  of,  354,   355, 

361 
eversion  of  os  calcis  in, 

344 
galvanic    current    in, 

353 

in  infants,  347 
manipulations  in,  347 
massage  in,  346,  353 
operations,  indications 

for,  346,  350 
osteo-plastic       opera- 
tions in,  358 
Phelps*  operation   in, 

356 
plaster  of  Paris  in,  348 


Talipes,  varieties  of, 

equino-varus,  treatment  of, 

Sayre's    apparatus  in, 

348 
Scarpa's  shoe  in,  348, 

354 

splints  for,  3^7,  348 
Syme's  amputation  in, 

358 

syndesmotomy  in,  351 
tarsectomy,  cuneiform 

in,  358 

tarsus,  resection  of,  357 
tenotomy  for,  350 
Thomas's   wrench  in, 

352 

when  deformity  can  be 
reduced  by  manipu- 
lation, 346 
equinus,  causes,  321 
changes  in,  322 
definition  of,  321 
degrees  of,  321 
treatment  of,  322 

first    group   of    cases, 

323 

exercises  in,  323 
division    of     tendo 
Achillis  in,  323 
accidents   during, 

326 
after-  treatment 

of,  326 
boot  for  use  after, 

328 

exercise  after,  328 
Sayre's  apparatus 

after,  327 
second  group  of  cases, 

329 

plantar  fascia,  di- 
vision of,  329 
third  group  of  cases, 

.   33i 

amputation  in,  333 

astragalus,  ex- 
cision of,  332 

boots  in  after- 
treatment  of, 

333 
partial    resection 

of,  333 

valgus,  definition,  312,  342 
pathological  changes,  342 
treatment,  342 

advanced  cases,  343 
apparatus  in,  343 
bones  of  legs,  division 

of,  344 
boots  in,  343 
douching  in,  342 
galvanic  current  in,  342 
manipulations  in,  342 


INDEX 


Talipes,  varieties  of, 

valgus,  treatment  of, 

massage  in,  342 
peronei     tendons,    di- 
vision of,  343 
tendon      transplanta- 
tion in,   343 
Whitman's   spring   in, 

343 
varus,  definition  and  treatment, 

312,  344 

Tapotement  in  massage,  23 
Tarsectomy,  cuneiform,  358 

after-treatment  of,  361 
splint  after,  360 
suture  of  incisions  in,  360 
Thomas's  wrench  in,  359 
partial,  for  pes  cavus,  334 
Tarsus,    changes    in    ligaments    of,    in 

equino- varus,  345 
osteo-plastic  operations  on,  358 
removal  of  wedge  from, 
in  flat  foot,  310 
talipes  cavus,  344 
equino-varus,  358,  360 
Teeth,  care  of,  in  secondary  syphilis,  218 
Tendo  Achillis, 

exposure  of,  337 
oblique  section  of,  337 
plastic  operations  on,  337-342 
shortening  of,  in  talipes  calcaneus,  3  36 
tenotomy  of,  323,  329,  331,  335,  350, 

353,  357,  361 
boot  after,  328 
in  talipes  equino-varus,  350, 

353,  357,  36i 
talipes  equinus,  323 
accidents  during,  326 
after-treatment  of,  326 
exercises  after,  328 
Sayre's  apparatus  after,  327 
transplantation  of,  indications  for, 

339 

treatment  after  section  of,  338 
"L-shaped     section     of,     in     talipes 

calcaneus,  338 
Tendon  lengthening  in  club-hand,  362 

transplantation,  340,  343 
Tenotomy  for  talipes,  318,  323,  329,  331, 

335,  343,  35°,  353,  357,  3^1 
Tertiary  syphilis,  211 

treatment  of,  224 
Tetanus,  199 

anti-tetanic  serum  in,  201 

bacillus,  200 

causes  of,  200 

death  in,  200 

chloral  in,  202 

chloroform  in  severe  cases,  203 

curative  treatment  of,  201 

definition  of,  199 

diet  in,  203 

drugs  for,  202 


Tetanus,  morphine  in,  203 
prodromata  of,  200 
prophylactic  treatment  of,  201 
symptoms  of,  199 
treatment  of,  201 
of  wound,  203 

trephining  to  administer   anti- 
tetanic  serum,  201 
varieties  of,  200 

Therapia  magna  sterilisans,  212 
Thermolabile,  509 
Thiersch's   method  of  skin-grafting,  53, 

157,  171,  256 
after-treatment  in,  58 
application  of  grafts  in,  56 
cutting  grafts  in,  54 
dressing  after  application  of  grafts, 

56 

changing  first  dressing,  57 
in  fresh  wounds,  157 

lacerated  wounds,  171 
preparation  of  ulcer  in,  53 
results  after,  59 

time  required  for  cure  after,  58 
Thoma's  haemocytometer,  491 
Thomas's  hip  splint  for  coxa  vara,  391 

genu  valgum,  374 
wrench,  308,  330,  351,  352,  359 
Thorax,  changes  in,  in  scoliosis,  408 
Thrombosed  vein,  removal  of,  in  treat- 
ment of  pyaemia,  193 
Thrombotic  gangrene,  75,  82 
Thyroid  extract  in  inoperable  cancer,  250 
Thyroidectomy,        administration        of 

anaesthetics    in,    469 
Tibia,  changes  in  genu-valgum,  372 
curved,  363 

division  of  for  genu  varum,  384 
genu  valgum,  381 
removal  of  wedge  from,  in  bow-legs, 

368 
Tibia    and    fibula,    curved,    chap.    xvii. 

363-370 

treatment,  363 
general,  363 
local,  365 

in  acute  anterior  cxirvature, 

367 

advanced  stages,  366 
early  stages,  365 
marked    curvature,    cases 

of,  367 
operation  for,  367 

after-treatment,   369 
choice  of,   367 
indications,  367 
osteotomy,  cuneiform,  368 
linear,  368 
oblique,   369 
splints  after  operation, 

duration  of  use  of,  370 
Gooch's,  369 
plaster  of  Paris,  370 


INDEX 


549 


Tibialis  anticus  tendon,  division  of,  350 
posticus     tendon,     division    of, 

35° 

Toe-post  in  hallux  valgus,  281 
Toes  and  fingers,  deformities  of,  275 
Toison's  fluid,  490 
Tongue  forceps,  475 
Torsion     as     a    means     of     controlling 

haemorrhage,  108 
Tourniquet  for  controlling  haemorrhage, 

1 06 

Towels,  antiseptic,  in  operations,  102 
Transfusion  and  infusion 
in  anaesthesia,  477,  479, 
haemorrhage,  112 
shock,  1 20,  121 

Traumatic  fever,  treatment  of,  188 
gangrene,  69,  83 

treatment,  83 
Trephining    to    administer    anti-tetanic 

serum,  201 
Triangular    wounds,    plastic    operations 

for,  159 

Trichinosis,  blood  count  in,  508 
Trismus,  200 
Trophic  ulcer,  42 
Tropocaine  as  an  anaesthetic,  484 
Tubercle,  definition  of  a,  230 

bacilli,  228 

Tuberculin,  use  of,  231,  236,  520-525 
in  diagnosis,  520 

treatment,  522 

Tuberculosis,  chap.  x;i.  228-236 
blood-count  in,  506 
caseation  in,  230 
chronic  abscess  in,  16,  230,  233 
definition  of,  228 
drugs  in  treatment  of,  232 
cod  liver  oil,  232 
guaiacol,  232 
nux  vomica,  232 
syrup  of  iodide  of  iron,  232 
factors  in  production  of,  228 
age,  229 
certain     conditions     connected 

with  bacilli,  229 
chronic  inflammation,  229 
climatic  conditions,  228,  231 
cold,  228 
general,  229 
heredity,  229 
injury,  228 
sepsis,  229 
sex,  229 

general  treatment  of,  231 
hygienic  conditions,  231 
massage,  232 

removal  of  chronic  inflamma- 
tion, 233 
rest,  232 
pathology,  230 
retrogressive  changes  in,  230 
seats  of,  228 


Tuberculous  abscess,  16,  230,  233 

disease    of    spine    as    a    cause    of 

scoliosis,  407 

hip  joint,  amputation  in,  192 
Tumours,  chap.  xiii.  237-265 
cellular  type,  238 
clinical  classification  of,  237 
composed  of  complex  tissues,  254 
connective  tissue  type,  243 

benign  varieties,  250 

malignant  forms,  243 
definition  of,  237 

malignant,  238 

simple,  238 
exploratory   incision   for   diagnosis 

of,  245 

histological  classification  of,  238 
operations  on  palliative,  248 
partial,  247 
radical,  246 
varieties, 

adenomata,  240 

angiomata,  255 

carcinomata,  241 

chondromala,  252 

complex,  265 

corns,  240 

cysts,  265 

endotheliomata,  243 

epithelial,  238 
benign,  239 
malignant,  241 

epitheliomata,  241 

fibromata,  251 

gliomata,"  255 

horns,  240 

lipomata,  251 

lymphadenoma,  264 

lymphangiomata,  264 

lympho-sarcomata,  264 

moles,  251 

myomata,  254 

myxomata,  250 

naevi,  255 

neuromata,  254 

osteomata,  253 

papillomata,  239 

sacro-coccygeal,  265 

sarcomata,  243 

warts,  239 

Turpentine  stupe,  13 
Typhoid  fever,  blood  count  in,  508 


ULCERATION,  chap.  iii.  39-66 

Ulcers, 

ambulatory  treatment  of,  59 
avoidance  of  irritation  in  treatment 

of,  49 

blisters  in  treatment  of.  49 
boric  lint   and  protective  dressing 

in  treatment  of,  51 
ointment  in  treatment  of,  51 


550  INDEX 

Ulcers,  callous,  44  Ulcers,  special  points   in   treatment  of 

special  points  in  treatment  of,  various  forms,  61 

63  callous,  63 
carbolic   acid,   undiluted,   in   treat-  diabetic,  65 

ment  of,  50  inflamed,  61 

oil  in  treatment  of,  50  irritable,  62 

causes  of,  39  paralytic,  64 

celluloid    shields    in   treatment  of,                      perforating,  65 

52  phagedenic,  63 

chloride    of   zinc   in    treatment  of,                       pressure,  64 

50  simple,  6 1 

chronic  infective,  39  varicose,  63 

non-infective,  39  weak,  61 

classification  of,  39  skin-grafting  in,  52 

constitutional,  45  Reverdin's  method,  52 

dangers  of,  46  Thiersch's  method,  53 

definition  of,  39  strapping  in,  47 

diabetic,  45  treatment  of,  46-66 

special  points  in  treatment  of,                      where  the  patient  cannot  lie  up, 

65  59 

diphtheritic,  44  trophic,  42 

disinfection  of,  49  Unna's  bandage  in  treatment  of,  60 

dressing  after  disinfection  of,  50  varicose,  44 

due  to  constitutional  causes,  45  special  points  in  treatment  of, 

duodenal  in  burns,  176  63 

elastic  bandage  in  treatment  of,  48               varieties  of,  43 

from  cold,  41  weak,  43 

haemorrhagic,  44  special  points  in  treatment  of, 

healing,  signs  of,  in,  42  61 

infective,  chronic,  39  wet  boric  dressing  in,  51 

inflamed,  43  Undermining    flaps,    to    close    wounds, 

special  points  in  treatment  of,  158 

61  Unna's  bandage  in  ulcers,  60 

irritable,  43  plasma  cells,  17 

special  points  in  treatment  of,       Urine,  molecular  content  of,  505 

63 

Martin's    bandage  in,  48,  59 

massage  in  treatment  of,  47  VACCINES,  514 

non-infective,  chronic,  39  counting  the  emulsion,  515 

paralytic,  45  dosage  of,  517 

special  points  in  treatment  of,               preparation  of,  514 

64  preparing  the  dilutions,  517 
perforating  of  foot,  45  sterilisation  of,  515 

special  points  in  treatment  of,               testing  sterility  of,  516 

65  treatment  by, 
phagedenic,  44  in  acute  septicaemia,  189 

special  points  in  treatment  of,                          cancer,  249 

63  diffuse  cellulitis,  38 
position  in  treatment  of,  47  wounds  that  cannot  be  kept 
preparation  of,  in  Thiersch's  skin-  aseptic,  163 

grafting,  53  Varicose  eczema,  44 

pressure,  44  ulcer,  44 

special  points  in  treatment  of,                      excisions  of  veins  in,  63 

64  special  points  in  treatment  of, 
pressure  in  treatment  of,  47  63 

principles  of  treatment  in,  46  veins  in  relation  to  ulceration,  40 

removal  of  cause  of,  46  Veins,  entry  of  air  into,  122 

rest  in  treatment  of,  46  treatment,  123 

rodent,  241  excision  of,  in  varicose  ulcer,  63 

treatment  by  radium,  249  Venesection,  4 

X-rays,  249  Venous  anaesthesia,  486 

signs  of  healing,  42  naevus,  255 

simple,  43  thrombosis  in  pyaemia,  193 


INDEX 


Vernon-Harcourt  inhaler  for  administer- 
ing chloroform,  463 
Vienna  mixture,  for  anaesthesia,  463 
Vomiting  after  anaesthesia,  478 
Von  Pirquet's  reaction,  520 
V-shaped  flap 

for  Dupuytren's  contraction,  295 
webbed  fingers,  272 


WALKING  apparatus 

in  genu  valgum,  374 

talipes  calcaneus,  336 
Warburg's  tincture,  190 
Warmth  in  treatment  of  shock,  120 
Warts,  239 

gonorrhceal,  239 
Wassermann   reaction  in   syphilis,   210, 

508,  510 
Fleming's    modification  of  making 

test,  511 

value  of  in  syphilis,  226,  513 
Water-bath    in     treatment    of     burns, 

179 

in  diffuse  cellulitis,  34 
Water-bed,  use  of,  in  bed-sore,  70 
Wax,  Horsley's,  no 
Waxy     degeneration    of    blood-vessels, 

190 
Weak  ankles,  310 

ulcer,  characters  of,  43 

nitrate  of  silver  in,  62 

red  lotion  in,  62 

special  points  in  treatment 

of,  61 

Webbed  fingers,  270 
treatment,  271 

Didot's  operation,  273 
ear-ring  perforation,  271 
V-shaped  flap,  272 
where  bones  are  united,  275 
web  is  broad,  271 

narrow,  273 
Wheel  exercises,  437 
Whitman's  spring, 

in  acute  flat-foot,  303 
hallux  flexus,  286 
metasarsalgia,  288 
talipes  valgus,  343 
Wet  boric  dressing,  51 

cupping,  7 
White  stasis,  13 
Wire  sutures,  silver,  95,  140 
Wounds,  chaps,  v.  vi.  vii.  viii.  87-184 
after-progress  of,  152 
already  septic,  165 

open  granulating  wounds,  treat- 
ment of,  165 

septic  sinuses,  treatment  of,  166 
cases  requiring  drainage,  149 
classification  of  incised,   132 
contused,  169 
drainage  of,  147 


Wounds,  drainage  of ,  indications  for,  149, 

187,  188 
dressing  of,  150 

how  to  change  dressings,  152 
when  to  change  dressings,  151 
exclusion  of  micro-organisms  from, 

99 
granulating  wounds,  treatment  of, 

165 

healing  of,  127 

incised  wounds,  chap.  vii.  132-167 
infective     diseases     of,     chap.     ix. 

185-203 

inflicted  accidentally,  163 
irrigation  of,  186 
lacerated,  170  *•' 

treatment  of,  171 
micro-organisms,  exclusion  of,  from, 

99 
modes  of  healing  of,  chap.  vi.  127- 

131 

by  blood-clot,  129 
granulations,  129 
first  intention,  127 
causes  of  failure,  154 
causes     inimical     to    healing, 
128 

union  of  granulations,  131 
under  a  scab,  129 
of  mucous  membranes,  161 

anti-streptococcic     serum     in, 

163 

chloride  of  zinc  in,  162 
iodoform  in,  162 
open     granulating,    treatment     of, 

165 

oval,  closure  of,  157 
parasites  in,  185 
pressure  in  dressing  of,  151 
poisoned,  172 

post-mortem  wounds,  172,  173 
punctured,  168 
quadrilateral,  closure  of,  158 
saprophytes  in,  185 
scalp,  treatment  of,  164 
sepsis,  occurrence  of,  155 

in  open,  160 
septic,  intoxication  of,  185 

sinuses  in,  166 

treatment  of.  165 

skin-grafting  in  fresh  wounds,  157 
sources     of     infection     by     micro- 
organisms, 99 

suturing,  methods  of,  133-143 
that  cannot  be  kept  aseptic,  161 
anti-streptococcic     serum      in, 

163 
treatment 

antiseptic  method  of,  99 
disinfection  of  skin,  99 

hands,  101 
instruments 
92 


552 


INDEX 


Wounds, 

treatment  of  sepsis  in  an  open,  160 
where  edges  are  not  brought 

together,  157 
plastic  operations,   157 
skin  grafting,  157 
without  antiseptics,  153 
triangular,  closure  of,  159 


Wrenching  in  talipes,  351,  352,  356,  359 

X-RAY  burns,  174 

X-rays  in  treatment  of  carcinoma,  249 
cheloid,  205 

"L-SHAPED  section  of  tendo  Achillis,  338 


END   OF   VOLUME  I. 


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SPOTTISWOODE  AND  CO.  LTD.,  COLCHESTER 
LONDON  AND  ETON 


I 


